1. CSI-RI Learning Collaborative October 9, 2014

3. David Gorelick, MD, FACP Full Time Practicing Internist Aquidneck Medical Associates in Newport since 1995 University Medicine Foundation member Jan 1, 2014 Lifespan Corporation Board of Directors RI HIE (CurrentCare) Advisory Commission Chairman No financial disclosures in relation to today’s presentation CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP

4. David Gorelick, MD, FACP Aquidneck’s Physician Champion EMR Super-User – fully electronic since 2005 EMR Training, Maintenance, and Upgrades Patient-Centered Medical Home – 1 st in RI NCQA Level 3 in 2009 Practice Transformation – workflow efficiency and staffing model All Quality and P4P Initiatives – 1 st group in RI MU in 2010 CSI-RI beginning Oct, 2013 Newport Hospital Code Committee Chairman since 1995 Newport Hospital Case Management Advisor since 1999 CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP

5. Today’s Discussion End of life care is an active intervention Whose wishes are we honoring? The patient’s? The family’s? The doctor’s? Patient-Centeredness Having the discussion Living Will Durable Power of Attorney for Healthcare Where does code status fit in? Comfort One MOLST Transitions of Care CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP

6. National Cancer Institute End-of-Life Care for People Who Have Cancer End-of-life care provides physical, mental, and emotional comfort, as well as social support, to people who are living with and dying of advanced illness. People who have already discussed their wishes for end-of-life care with their loved ones feel less stress at the end of their life, and so do their families. Advance directives are legal documents that record a person’s wishes for end-of-life care. Research has shown that hospice care may improve the quality of life of a cancer patient who is dying and of the patient’s family. CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP

7. Hospice Care National Hospice and Palliative Care Organization http://www.nhpco.org/ http://www.nhpco.org/ Considered the model for quality compassionate care for people facing a life-limiting illness. Hospice provides expert medical care, pain management, and emotional and spiritual support expressly tailored to the patient’s needs and wishes. Support is provided to the patient’s loved ones as well. Hospice focuses on caring, not curing. CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP

8. Case Report – 95y/o with anemia Interventions vs conservative approach Patient’s wishes were clear Family’s agenda differed CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP

9. Case Report – 80y/o not recovering Seizure disorder and IDDM since childhood Advanced cardiac disease Hip fracture, post-op course gone bad Patient’s wishes were clear, family agreed Intensivist “interventions are necessary to help her”. Whose wishes are being honored? CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP

10. Case Report – 68y/o end stage cancer Pain management issues Patient/family consensus – pain control overnight, then home with Hospice Admitting physician “we can fix this” One week hospitalization with supportive care interventions Whose agenda is it? CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP

11. Patient-Centered Respect patients’ beliefs - ethical, religious Honor the patient’s wishes Help family through the process Consider Ethics Committee consultation if there are conflicts CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP

12. Not Physician-Centered Objective advice and support We don’t facilitate death, but we can actively comfort patients at the end of life Don’t let technology and medical advances stand in the way of patients’ right to die. CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP

13. Have the Conversation In times of health as well as illness Advanced Directives – even the young Durable Power of Attorney - same Resuscitation/Code Status - 65+, others with advanced illnesses CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP

14. Have the Conversation Again In times of health as well as illness When situations change Build it into the workflow EMR structured data section Reporting Pre-visit planning CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP

15. Share the Wishes Primary Care Physician Family Local hospital Statewide Health Information Exchange With each transition of care CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP

16. Case Report – 92y/o acute abdomen Patient’s wishes were clear PCP provided support to emphasize patient’s wishes Hospital service attending kept swaying the family towards intervention “we need to operate, would you rather do nothing and let her suffer?” CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP

17. End of Life Care is an ACTIVE intervention CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP

19. R.I. Living Will Rights of the Terminally Ill Act Declaration http://www.health.ri.gov/forms/legal/LivingWill.pdf A Declaration I voluntarily make known my desire that my dying shall not be artificially prolonged… If I should have an incurable or irreversible condition that will cause my death… CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP

20. R.I. Durable Power Of Attorney For Health Care http://www.health.ri.gov/forms/legal/DurablePower OfAttorneyForHealthCare.pdf http://www.health.ri.gov/forms/legal/DurablePower OfAttorneyForHealthCare.pdf An Advanced Care Directive Appointment of Health Care Agent to make health care decisions if you can no longer make decisions Two qualified witnesses or one notary public must sign CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP

21. R.I. Durable Power Of Attorney For Health Care If I am close to death and life support would only prolong my dying If I am unconscious and it is very unlikely that I will ever become conscious again If I have a progressive illness that will be fatal and is in an advanced stage CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP

22. Living Will/POA – Code Status? Distinguish between “life support” when life brings you towards the end with a terminal condition vs Code Status DNR should not have a menu of options Comfort One CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP

23. Comfort One http://www.health.ri.gov/publications/hand books/ComfortOneEMSDoNotResusitatePro gram.pdf http://www.health.ri.gov/publications/hand books/ComfortOneEMSDoNotResusitatePro gram.pdf Bracelet applied to the patient EMS can provide care without “threat” of resuscitation Terminal illness diagnosis Advanced age, frail, failing to thrive? CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP

25. Comfort One Bracelet CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP

26. MOLST Medical Orders for Life-Sustaining Treatment http://www.health.ri.gov/lifestages/death/ab out/medicalordersforlifesustainingtreatment/ http://www.health.ri.gov/lifestages/death/ab out/medicalordersforlifesustainingtreatment/ http://www.health.ri.gov/forms/medical/Ord ersForLifeSustainingTreatment.pdf http://www.health.ri.gov/forms/medical/Ord ersForLifeSustainingTreatment.pdf Stand-alone, portable orders that follow the patient from facility to facility. CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP

27. MOLST - elements CPR Medical Interventions Transfer to Hospital Artificial Nutrition Artificial Hydration Advance Directive CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP

30. Transition of Care Interpreting patient’s wishes as they apply to the current situation may be a challenge Involve the family Involve the healthcare team Inpatient MD’s, RN’s NCM’s – inpatient and outpatient PCP’s Clergy Leave egos at the door – focus on the patient CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP

33. CSI-RI Learning Collaborative October 9, 2014