1. Updates in Advance Care Planning
Sarah Beth Harrington, MD
Associate Professor
Department of Internal Medicine
Division of Palliative Medicine
Chief, CAVHS Palliative Care
AD, Surrogate decision making, polst

3. Advance Directives Completion rate Higher rates associated with
Older age
More education
Higher income
Caucasian
Chronic disease
Barriers
Variable depending on source – highest from the HHS study – 26% - phone survey

4. AD: Two parts
HCPOA - Who do you trust to make medical decisions for you if you lose capacity?
Living Will - What are things you do or don’t want if you had a terminal/irreversible illness?

5. Practice Who can discuss AD? How can you start the conversation?
How to complete? Who can witness?
What do you do with it?
Outpatient vs. Inpatient approach?
“gift”
Standardize

6. Misconceptions about Advance Directives
A patient must have an AD to stop treatment near the end of life
An AD means “Do Not Treat”
Naming a Proxy means the patient gives up his right to make his own decisions
A patient must be certain of what she wants before making an AD
A living will is the same thing as a legal will
An AD is only for terminally ill

7. A Conversation

8. Those with an AD are more likely to receive EOL care consistent w/ their preferences
83.2% of pts who requested limited care received it
97.1% of pts who requested comfort care received it
Without an AD, 32% of the time a pt’s surrogate will incorrectly choose the desired treatment
Tejwani V et al. (2013) Issues Surrounding end of life decision-making. Patient preference and Adherence 7,

9. The evolution of Advance Directives
Recent studies – AD substantially improve the patient centeredness of care near the EOL
Evidence about effect on costs – conflicting & incomplete
Despite efforts – AD completion rates remain small
Should we be thinking about things differently?
In contrast to early studies suggesting little benefit of AD, recent observational and interventional studies in select populations suggest
Regional differences
Depite monumental public ed efforts, completion rates for AD are suboptimal
Silveira MJ, Kim SY, Langa KM NEJM 2010
Detering KM et all BMJ 2010

10. Moving beyond the “boiler plate” AD
Facilitated ACP
Video decision support tools
Moving towards preparation of surrogates for in-the-moment decision-making
Triad = clinician-patient-surrogate
Pts authorize or refuse al ist of medical treatments
Innovative approaches - facilitated ACP – ex. VA
Led to higher rates of documentation of preferences, greater stability of preferences, improved EOL care and bereavement care for families
Sudore – Prepare for your Care
Moving away from documenting tx preferences for specific medical scenarios towards preparation of surrogates
This looks very different from the original version of pt/clinician documentation
Volandes AE et al J Am Dir Assoc 2009.
Volandes AE et al BMJ 2009
Sudore RL, Fried TR Ann Int Med 2010

11. Updates in ACP: AR Law Arkansas Health Care Decisions Act (2013)
What’s different
Surrogate definition/ designation
Role of the physician
Guidance for the “unfriended” patient

12. Arkansas Health Care Decision Act Senate Bill 1013, enacted 10/14/2013 in the 89th General Session
“An act to create the Arkansas Health Care Decisions Act; to protect patients’ rights to make their own health care decisions; to promote advance directives; to provide legal protection for patients’ rights; and for other purposes.”
This act revokes all previous similar Acts.
Arkansas Rights of the Terminally Ill or Permanently Unconscious Act (ARTIPUA) (1987)
Durable Power of Attorney for Healthcare (1999)

13. Who can make an Advance Directive?
An adult aged 18 or over, or
An emancipated minor, as determined by a court of law,
Who must have the capacity to understand, make, and communicate medical decisions

14. When is an AD official? The document must be signed by the patient.
The signature must witnessed
by two adults 18 years of age or older, neither of whom can be treating the patient, nor be the Agent/Proxy appointed in the AD
and at least one of whom must be a “disinterested party”, i.e. someone who is not related to the patient by blood, marriage, or adoption, and who would not benefit from the patient’s death.
Or the signature may be witnessed by a Notary Public.
A lawyer does NOT need to be involved.

15. So Who Makes Decisions? The Patient The HCPOA The Designated Surrogate
Always trumps an Advance Directive
The HCPOA
If patient lacks capacity
The Designated Surrogate
Designated by the patient
Designated by the physician
Physician him/herself

16. New concept: Surrogate Decision-Maker
Anyone chosen by the patient to serve in this role
The patient must have capacity.
The patient must designate in a signed written document or directly to an attending physician.
Chosen by the physician - no longer a hierarchy
It can be a neighbor, school friend, guy from the Elks Lodge.
“Consideration may be given” to the spouse, adult child, parent, adult sibling, any other adult relative – but no longer is this hierarchy required
In the absence of a HCPOA or AD

17. Can the Physician Choose a Surrogate?
If the patient is incapacitated and has not named a DHCPOA, the patient’s physician has the right, authority, and duty to name a single, specific Surrogate Decision Maker for Health Care
Adult who has exhibited special care and concern for the patient, preferably with frequent contact,
Who is familiar with the patient’s personal values,
Who has the ability to make decisions in accordance with the patient’s known wishes and values and/or in the patient’s best interests,
Who is reasonably readily available and is willing to serve, and who is not the subject of a protective court order that directs that that person avoid contact with the patient.

18. Can the Physician be the Surrogate?
If none of the individuals eligible to act as a surrogate is reasonably available, the attending physician may make healthcare decisions for the patient after the physician:
Consults the institution’s ethics committee, or
Obtains concurrence from a second physician who is:
Not directly involved in the patient’s health care
Is neither a supervisor of the attending physician or supervised by the attending physician
Both conditions are required at UAMS
Any challenge to the selection of the surrogate has the burden of proving the invalidity of that selection by a preponderance of evidence.

19. Can a patient change her/his mind?
A patient with capacity may revoke or change all or part of her or his advance directive at any time. This must be done in writing or verbally face-to-face to his or her attending physician who then must document the change in the patient’s medical record.
A decree of annulment, divorce, or legal separation automatically revokes a previous designation of a spouse as agent unless the decree or directive specifically provides otherwise.
“Unfriended pt”

20. What’s our Liability?
A healthcare provider or institution acting in good faith and in accordance with generally accepted healthcare standards is not subject to civil or criminal liability or to discipline for unprofessional conduct for:
Complying with a health care decision of an agent apparently having authority to make such decisions
Declining to comply with a health care decision of a person based on a reasonable belief that the agent lacks authority
Complying with an AD that to the knowledge of the provider was valid when made and has not been revoked
Ex.

21. In practice . . . . Patient w/o capacity has an AD + decision-maker?
What does it say? Is it signed/ legal?
Is it specific or broad?
What condition is specified in the AD?
Is the condition irreversible/ reversible?
Use in conjunction with the HPCOA to translate into a plan / set of orders
Pt w/o capacity with an AD and NO FAMILY
Family disagrees with AD?

22. Questions? Cancer.net The Conversation Project Prepare for Your Care
Get Palliative Care
CaringInfo
Making your Wishes Known
ACPDecisions.org

23. POLST: Understanding Physician Orders for Life-Sustaining Treatment in AR

24. Act 504 (2017) Senator Missy Irvin, Representative Mary Bentley
Friends – Dr. David Smith, Patrick McGruden – CHI, AHA, HPCAA, AR Hospice
#49

25. Why POLST?
The current standard of care during an emergency is for emergency medical services (EMS) to attempt everything possible to attempt to save a life.
Not all patients who are seriously ill or frail want this treatment and POLST provides the option for them to:
confirm this is the treatment they want - CODE STATUS
(2) to state what level of treatment they want.

26. What is a POLST form?
Portable medical order form used to record a patient’s treatment wishes that can be used across settings of care.
The POLST form records patients’ treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency.

27. Who needs a POLST form?
A POLST Form is intended to be used by individuals with a serious illness or frailty toward the end of life.
Life expectancy of < 1 yr

28. Who needs a POLST form?
All competent adults should have an advance directive, documenting who they want to speak for them whenever they lack capacity to speak for themselves. 
Both advance directives and POLST Forms are advance care plans.  They support each other but do different things.

30. Part A
Cardiopulmonary Resuscitation (person has no pulse and is not breathing)
Attempt Resuscitation/ CPR
Do Not Attempt Resuscitation / DNR/ Allow Natural Death
Rather than automatically going to the hospital, a POLST may help keep the patient comfortable where they are located, if that is the treatment level they have chosen.

31. Part B Medical Interventions: (Pt has a pulse and/or is breathing)
FULL TREATMENT: meaning that they want to go to the hospital and that all treatment options should be considered, including use of a ventilator;
LIMITED INTERVENTIONS: meaning that they want basic medical treatments but wish to avoid the intensive care unit (ICU); or
COMFORT MEASURES ONLY: meaning that they do not wish to go to the hospital but want to be made comfortable wherever they are living.

32. Part C
Additional Orders

33. How Does POLST Work?
Physician discusses continued health care options with patient and families in the context of
Diagnosis
Prognosis
Available treatment options
Burdens and benefits of available options
Patient goals and values

34. How Does POLST Work?
Actionable Order Set
Honored Across Settings

35. Who can complete a POLST form?
A POLST Form is completed by a physician in conversation with the patient.
Medical Order – must be signed by a physician to be valid
Patients should not be provided a POLST Form to complete on their own. 
AR –physician
Other states – Pas/ APRNs can sign –
Most states also require the patient or their surrogate sign the form.
We are already having these conversations every day – there’s no way to have it translated into an actionable plan w/o polst
A POLST Form should never be completed without a conversation with the patient, or his/her surrogate, about diagnosis, prognosis, treatment options and goals of care.

36. Is POLST same as Advance Directive?
POLST is not an advance directive but an actionable medical order.
POLST is only for seriously ill patients for whom their physician would not be surprised if they died in the next year.
It would be inappropriate for a HCP to complete a POLST form for a patient who is outside the intended POLST patient population.

37. Advance Directive vs. POLST
All adults
Provides instructions for future treatment
Appoints a HCPOA
Can be completed only by a pt with capacity
Does NOT guide Emergency Personnel
Guides inpt treatment decisions when made available
Pts with serious illness (< 1 yr)
Provides medical orders for current treatment
Can be completed by a pt with capacity OR a surrogate
Honored by Emergency Personnel
Guides inpt treatment decisions when made available

39. Is a POLST form mandatory?
No!
Completing a POLST Form should always be voluntary.
If someone is being forced to complete a form, contact or his/her state can contact National POLST paradigm at

40. Can POLST form be modified?
Yes!
POLST Forms were created to be easily modified and updated.
Physicians are encouraged to review your POLST Form periodically
As your medical condition changes or your goals of care change, you can update your POLST Form anytime by talking with your Physician.
Review form;
especially when you are transferred from one care setting or care level to another (e.g., upon admission and discharge from every facility) or when there is a substantial change in your health status.

41. Can POLST form be voided?
Yes. Easily Voided.
On the backside, the POLST Form has information about how it can be voided (usually by drawing a line across the form and writing “VOID” in large letters).
Update team and medical record.
If you ever decide that a POLST Form is no longer appropriate for you, it is also easily voided. It is preferred that you consult your health care professional to void your form.

42. What if a patient can no longer communicate their wishes?
The surrogate that a patient has appointed on his/her advance directive can help the healthcare professional complete a POLST Form based on their understanding of their loved one’s wishes.
The surrogate then signs the POLST Form on behalf of their loved one. 

43. Does a POLST form allow for basics like food and water?
Of course.
Endorsed POLST Forms state that ordinary measures to improve the patient’s comfort, and food and fluid by mouth as tolerated, are always provided. However, POLST Forms allow you to choose whether you would like artificially administered hydration/nutrition.
AR form – blank space

44. Is POLST portable? Yes – across settings!
POLST forms are state-specific. Patients who move should complete a new form with their physician.
Institution-specific / policies
Working on UAMS policy
Order set, AD
Working on Advance care planning tab – chart review
One place for everything

45. Where can one get a POLST form?
From Healthcare provider
Neon form = original
Copy accepted
**health care decisions forms**

47. Where should one keep a completed POLST form?
A POLST Form always remains with the patient, regardless of whether the patient is in the hospital, at home or in a nursing home.
The form should be placed in a visible location recognized by emergency medical personnel (usually the front of the refrigerator or bedside).
In a health care facility a copy of the POLST Form should be in the medical record.

48. 20 yrs of research
Strong relationship b/t POLST comfort treatment orders and location of death (34% vs. 6% died in hospital)
More likely to enroll in hospice at the EOL
Significant associations between POLST use in NH with scope of tx orders and level of treatment received
Average time of POLST completion and death ~ 6.4 weeks
Cancer (5 weeks), Dementia (14.5 weeks)
1990s
deaths in OR – relationship b/t polst and location of death
3 state study of 1711 residents in 90 NH
18,285 deaths polst forms

49. Case 1
Ms. A is a 95 yo WF with end stage dementia who is a NH resident. EMS is called to the NH by distressed staff after the patient is found minimally responsive, hypotensive, likely septic from aspiration pneumonia. POLST form given to EMS. Family on the phone and confirm wishes, requests hospice; APRN at the NH confirms that they contract with a local hospice and can provide comfort care in the NH.
Change scenario – NH freaking out – unable to do anything but push for patient to leave ASAP
Communication with ED?

50. Case 2
Mr. C is a 75 yo WM Veteran with a h/o severe COPD s/p multiple intubations. Pt signed a POLST form at his last admission. EMS called to pt’s home. He is in respiratory distress and is hypoxic. He is able to speak in short sentences and wishes to go to the hospital. He does NOT wish to be intubated. Sats improve with O2 in the ambulance. EMS reviews pt’s POLST on the way to the ED.
Trial of Bipap reasonable, abx, improvemenet

51. Case 3
Ms. B is a 55 yo female with metastatic NSCLC undergoing 4th line chemotherapy. Pt found down at home by family. They are too distressed to answer questions. Her POLST is on the refrigerator. She has a pulse but is breathing irregularly and lips are blue.

52. Goals for the future
More communication education, more support for GOC conversations
Standardize Advance Care Planning
Identifying patients with a poor prognosis and targeting ACP
Palliative Care Access / Training
More research in ACP tools and outreach
Pt’s plan of care matches their goals of care

53. Questions?