2. A Primer for Home Health Clinicians

3. Advance Care Planning: The Role in Population Health Management Population Health Management is focused on managing patients with chronic illness in a more proactive, anticipatory manner. Most chronic illnesses have a predictable trajectory. How do we prepare patients in a more responsible and sensitive manner to the path that their illness will most likely take? How can we as home care providers: a. Engage patients in conversations about their disease pathway? b. Enpower patients to participate in their careplanning process?

4. Could This Happen In Roanoke? Mr. Dehart, a 71 year old patient with severe COPD and mild dementia, resides at home with his wife. He develops increasing SOB and his wife calls 911. When EMS arrives, the adult daughter, visiting from out of town, advises them the family wants everything done. The wife does not mention her husband’s DDNR. EMS staff, having found the patient unresponsive, try to intubate him, but cannot. They insert an oral airway and transport the patient to the ER. Mr. Dehart remains unresponsive with a RR of 8 and an O 2 sat of 85% despite supplemental O 2. Pursuant to a chest X- ray, the ER physician writes, “full code for now, status unclear.” The staff intubate Mr. Dehart and transfer him to the intensive care unit.

5. What Went Wrong?

6. DDNR order not communicated to EMS and in subsequent transfer. Advance directive not documented. (Do you think advance directive would have been followed in this situation if it were documented?) Family at odds with patient’s wishes. Lack of communication between healthcare providers – treating clinicians left out of loop. Results include overtreatment of patient with unnecessary physical discomfort, costs, and prolonged dying process.

7. “ The problem with communication is the illusion that it has been accomplished.” - George Bernard Shaw

8. Common Issues With Advance Directives Advance Directives (AD) frequently use statutory language that can be hard to understand. Healthcare staff trying to assist patients in completing an AD often focus on how to complete the form, not adequately discussing the issues at hand. Focus has been more on legal rights and less on help for patient in making informed decision about his/her individual care.

9. Story of Stephanie Martin Glennon January 2013 – Stephanie’s husband, a physician and internist was diagnosed with metastatic pancreatic cancer. “No one but my husband and I seemed to want to talk about [that care]. With unwavering support of friends, we were able to get my husband home only by going rogue [when a] medical director was resistant to sending him home, and was suggesting yet more procedures he did not want and could not endure. We took him home, where he was surrounded by us and friends and other family members, surrounded by our children’s artwork and pictures and music – and where, for the first time during this ordeal, he encountered no pain and no nausea and finally was in comfort. He was able to speak and laugh and reminisce until he slipped into unconsciousness on his very last day and died peacefully, without medical interventions he never wanted.”

10. What is POST? A physician order Can be completed by a non-physician provider such as an NP or PA as well an MD or DO (Osteopath) Complements, but does not replace, advance directives Voluntary use Recognized by EMS as a valid DDNR 9

11. Who Is Eligible For POST? 1. Seriously ill persons, i.e., those with chronic, progressive disease 2. Terminally ill persons

12. Conversations that change over time Source: Carol Wilson, Riverside Health System; Used with permission Healthy Adults: Emergency Planning People with Progressive Illness: guided planning End Stage Illness: Physician Orders for Scope of Treatment

13. Who Is Eligible For POST? Prompt for POST completion: Would I be surprised if this patient died in the next year?

14. Living Will vs. POST (Remember: Patients may have both forms.) Living Will* For every adult regardless of health Decisions about open- ended myriad of treatments Needs to be retrieved Normally requires interpretation (*Hastings Center Report 2004; 34: 30 – 42) POST For seriously or terminally ill adults Decisions among presented treatment options Stays with patient Physician’s order for specific treatment(s)

15. Purpose of POST To provide a mechanism to communicate patients’ preferences for end-of-life treatment across treatment settings To improve implementation of advance care planning 14

16. Expected Outcomes of Using POST Process Improved continuity of care—Form transferable across treatment settings Clearer communication of wishes Reduced hospitalization and inappropriate life- sustaining treatments Fewer EMS transports More accurate representation of preferences Higher adherence to wishes by medical professionals.

17. POST Can Be Completed In Many Settings

18. The Conversation POST discussions must be facilitated by the patient’s physician or a trained Advance Care Planning Facilitator (ACPF). The facilitator may choose to involve other members of the patient’s healthcare team as well. The dialogue may or may not result in the completion of a POST document, but it does create an environment of shared and informed decision making for the patient facing serious illness.

19. Role of ACP Facilitator 1. Explores patient’s understanding of advance care planning and the role of a healthcare representative. 2. Explores understanding of medical condition, including possible complications that may occur. 3. Provides meaningful context for decision making through identifying previous key healthcare experiences, fears & worries, values, and important beliefs. 4. Explores patient’s understanding of CPR, comfort care, antibiotics, artificial nutrition and hydration, etc. 5. Ensures that patient’s wishes are clearly documented on transferable form. 6. Develops list of pertinent questions that may involve physician and others.

20. Why an Advance Care Planning Facilitator (ACPF)?

21. Why an ACPF? Has received training in having discussions with patients and POA’s about preferences for EOL care Training was based on our POST form The Advance Care Planning process takes about 45 minutes and often involves follow-up and/or additional sessions It is important that POST form is not just a check off sheet---an ACPF can make sure people know and understand their options

22. Who in our family are ACPs? Megan Moore, Hospice Social Worker Roanoke Debbie Quick-Conner, Hospice Social Worker Roanoke Nicole Bailey, Home Health Social Worker Tina Smusz, Hospice Medical Director Lisa Sprinkel, Home Care and Hospice Leigh Faulconer, Hospice Social Worker NRV Sharon Crane, Hospice Social Worker NRV

23. How to Complete a POST Form Must be completed by a physician or by a non- physician health care professional who has been trained as a POST Advance Care Planning Facilitator (ACPF). Must be based on patient/resident preferences Must be signed by an MD or DO Next form revision (in mid 2013)—NP’s and PA’s will be able to sign

24. POST Form

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27. Section A: Resuscitation Only section applicable to EMS These orders only apply if a person is pulseless and apneic. This section does not apply to any other medical circumstances. POST recognized as a valid Virginia Other DNR When Do Not Attempt Resuscitation is checked, qualified healthcare personnel are authorized to honor this order as if it were a Durable DNR order OEMS approval (Michael Berg) If a patient is in a “qualified health care facility” such as a nursing home or home on routine hospice care, a Durable DNR AND POST form is not needed. The POST form is preferred due to its comprehensive nature. 26

28. Section B Person Has Pulse and/or is breathing - Comfort Measures -Limited Additional Interventions -Full Interventions – All care above plus intubation and cardioversion Note re: antibiotics: Antibiotics are often life-sustaining treatments, so advance care planning can help clarify goals of care in order to make the best decision. It may be helpful to explain other treatments such as antipyretics and opioids to treat symptoms of infection and maintain comfort. 27

29. Section C: Artificial Nutrition Can be emotionally laden discussions. Emphasize the medical nature of this decision. Explain the medical, legal and ethical justification that artificially administered nutrition is a medical intervention that can be accepted or declined based upon the patient’s goals, values and priorities. Surrogate decision makers can consent or decline the intervention based upon their substitute judgment for the patient. Address any and all fears of neglect and abandonment. 28

30. Signatures 29

31. Back Side of Form Signature of the health care professional preparing the form. Directions for Health Care Professionals 30

32. Location And Transfer Of POST Form

33. Location Of The POST Form It is best if the original POST form (canary yellow color) accompanies the patient when transferred or discharged. A copy is acceptable, however, if the original document is not available. The POST form is transferred in a large red envelope, which stays with the original document (see next slide). In Hospital or Nursing Facility: Will be kept in the very front of patient’s chart. In Patient’s Private Residence: should be kept on refrigerator door, either in red envelope or with easy access to red envelope.

34. The Red Envelope for Transfer/Discharge

35. Envelope Label ORIGINAL POST/DDNR Form Enclosed Form is to accompany Patient upon Discharge/Transfer PLEASE RETURN ORIGINAL FORM IN THIS ENVELOPE TO: (Patient Name) (Address)

36. Transfer Of POST With Patient Red envelope with original POST should be placed on top of transport papers. The healthcare facility initiating the transfer shall communicate the existence of the POST form to the receiving facility prior to the transfer. The POST form shall accompany the person to the receiving facility and shall remain in effect.

37. Modifying POST Decisions

38. To Review, Change, or Void POST Review of Form is required when: 1. The patient’s preferences change 2. Patient is transferred from one healthcare setting to another setting, including admission to hospice care. 3. Patient has significant change in health.

39. To Review, Change, or Void POST Patient should always be involved in review process, as well as his/her representative. An ACP Facilitator and/or patient physician/NP/PA is preferred to lead review process. When patient is new to our service, but already has a POST form in place, the review should be coordinated.

40. To Review, Change, or Void POST There are 3 possible review outcomes:  NO CHANGE  FORM VOIDED, new form completed Complete a new form indicating the patient’s current wishes After doing so, write the word “VOID” in large letters across the both the front and back of the original POST form, and include the date the form was voided. Keep the original in the patient’s medical record to be archived according to agency policy. The new form will be kept with the patient if living at home or in front of the facility’s chart where her or she is located.  FORM VOIDED, no new form

41. When Not To Complete A POST Form A POST form should not be completed if the patient requests contradictory orders. One of the most likely examples: the patient wants CPR in Section A, but wants only limited additional interventions in Section B. The performance of CPR requires full treatment. If the patient does not want full treatment, including intubation and mechanical ventilation in an ICU, then the patient should not receive CPR.

43. Take-Home Messages POST provides a better means than AD to identify and respect patients’ wishes POST completion will improve end-of-life care throughout the system Use of POST will require communication to make it work in your community Know your role. “Where’s the POST form?” 42

44. POST Resources Palliative Care Partnership of the Roanoke Valley www.pcprv.org Contact Person for POST: Laura Pole, lpchef@earthlink.net lpchef@earthlink.net Virginia POST Collaborative www.virginiapost.org Respecting Choices www.respectingchoices.org See list of attached area professionals who are certified as Trainers and/or Facilitators in Advance Care Planning