Becoming Conversation Ready Kevin Mathews MD, FAAFP Director, Palliative Medicine Service Jeanne Tracy RN, BSN Director of Nursing/Quality Improvement St Luke’s Home. Evelyn Kropp, RN, BPS, CPHQ Palliative Medicine Navigator

One Conversation Can Make All the Difference Consider the facts 90% of the people think it’s important to talk about their loved ones’ and their own wishes for end-of-life care. 30% of people have had the discussion Source: National Survey by The Conversation Project 2013. 60% of people say that making sure their family is not burdened by tough decisions is “extremely important” 56% have not communicated their end-of-life wishes Source: Survey of Californians by the California HealthCare Foundation (2012) 70% of people say they prefer to die at home 70% die in a hospital, nursing home, or long-term-care facility Source: Centers for Disease Control (2005) 80% of people say that if seriously ill, they would want to talk to their doctor about end-of-life care 7% report having had an end-of-life conversation with their doctor One Conversation Can Make All the Difference

Imagine a world where early advance care planning is normal. Where people routinely identify a health care agent And provide guidance to their agent, family and healthcare providers regarding their wishes if faced with a catastrophic Illness. According to the new IOM report,”Dying In America” that should be a primary goal of the health system in the US.

Are We Ready? 80% of people say that if seriously ill, they would want to talk to their doctor about end-of-life care, 7% report having had the conversation with their doctor How often do we ask ourselves-why are we doing this? How often do we say-”That will never be me!” Are we ready for a patient population eager to discuss end of life care?

Core Principles Engage with our patients and families to understand what matters most to them at the end of life Steward this information as reliably as we do allergy information Respect people’s wishes for care at the end of life by partnering to develop shared goals of care Exemplify this work in our own lives so that we understand the benefits and challenges Connect in a manner that is culturally and individually respectful of each patient

St. Luke’s Home Engagement with the Conversation Ready Project

First step was to evaluate how we are currently discussing advance care planning and end of life wishes with our residents and new admissions.

Prior to Conversation Ready Few conversation regarding advance care planning took place until 14 days from admission and it was social worker only MOLST forms were not completed at time of admission, completed by day 14 The environment surrounding the meeting was not conducive Lack of staff education

Since introduction of the Conversation Ready Project All staff were educated on Palliative care-weekly webinars were conducted Medical staff, nursing and social work meet with family MOLST forms are started on admission and conversation regarding wishes and goals of their health care continue without stay

Re-development of our palliative care program Residents on the palliative care program are on our 24 hour report sheet and the IDCP team discuss the plan of care daily

Environment for the conversation prior

Our new meeting room

Where do we go from here Data collection E-MOLST Continue with education for all staff members Nationally certify C.N.A., LPN’s and RN’s

Emphasis to staff Not to lose sight that we abide by the wishes of our residents for what they want in medically, spiritually and culturally.

Steward this information as reliably as we do allergy information

Stewardship Issues Identified Advance Directives were completed but not available in the current chart. Redundant processes lead to conflicting information Electronic storage of information was not easily accessible by the clinicians caring for the patient.

Lack of forms in the chart Unit Secretaries were given access to the scanned records and taught how to go in and print previous copies. This increased the rate of having an actual HCP form in the chart from 9 to 28 %

Redundant processes lead to conflicting information Patients were asked at registration and on the unit for information regarding their Advance Directives. 20% of the time there was a disagreement between what the patient was saying and what reality was. Inpatients will only be asked by a nurse.

Electronic storage of information was not easily accessible by the clinicians caring for the patient Stored in a obscure section of the EMR. Now is stored in the Adult Patient Profile and the information is readily accessible in the electronic kardex and other “snapshot” views. ADT system could only store 1 relationship- ie HCP or daughter, but not both. Clinical information stores both.

Past Conversations

Current Conversations

Future Conversation

Who Controls OUR Conversation?