1. Communications during Life Limiting Illness & POLST in SC Walter Limehouse, MD, MA MUSC Ethics Comte

2. Objectives Identify SC Coalition for Care of Serious Illness (SCC-CSI) Outline MUSC clinical policy C-169 Describe POLST in SC: POST

3. Serious Illness Communications SCMA & SCHA –revisit “medical futility” concern (2010) SCMA annual meeting resolution, May 2010: STANDARD COMMUNICATION, CONSENT AND DECISION-MAKING PROCESS FOR SERIOUSLY ILL INPATIENTS IN SOUTH CAROLINA

4. Serious Illness Communications SCMA House of Delegates, May 2010 Determine decision-making capacity according South Carolina law; Determine decision makers or surrogates; Determine patients’ understanding, beliefs, values, and wishes; Facilitate effective communication; and Call palliative care and/or ethics consults to address concerns.

5. SC Coalition for Care of Serious Illness (SCC-CSI) Charter groups represent diverse state- wide interests SC Medical Association SC Nurses Association SC Hospital Association SC Healthcare Ethics Network Carolinas Center for Hospice & End-of-Life Care SC Society of Chaplains, LifePoint, AARP

6. SCC-CSI Vision Statement SC delivers excellent communication and shared decision-making for persons with serious, chronic, or terminal illnesses

7. SCC-CSI Initiatives @ MUSC Improving communications clinical policy C-169 Communication Process for Inpatients with Life Limiting Illness POLST Physician Orders of Life Sustaining Treatment POST in SC Physician Orders on Scope of Treatment

8. MUSC Clinical Policy C-169 Communication Process for Inpatients with Life Limiting Illness

9. Life-limiting illness triggers for communications process Terminal illness with projected death within 6 months Chronic debilitating illness with readmissions and/or multiple ED visits Major events, like stroke, resulting in direct ICU admission or transfer Other illnesses, as so determined by the attending physician

10. Process Facilitator Nurse case manager or social worker as shepherd facilitates completion of process forms with medical team schedules meetings as needed to develop or revise goals of treatment may document meeting discussions and attendance.

11. Process follows SCMA resolution Determine decision-making capacity Determine decision-makers or surrogates Determine patients’ understanding, beliefs, values, and wishes Facilitate effective communication and shared decision-making for time interval Call palliative care and/or ethics consults to address concerns

12. Forms Serious Illness Planning Progress Note https://www.musc.edu/cce/ORDFRMS/pdf/all_all_docu_seriousillnesspl anningprognote.pdf https://www.musc.edu/cce/ORDFRMS/pdf/all_all_docu_seriousillnesspl anningprognote.pdf Serious Illness Continuing Care Planning Progress Note

13. POLST paradigm Physician Orders on Life Sustaining Treatment Physician orders scope of resuscitative treatment during life threatening emergency Advance planning with patients patient death not unexpected within 1 year Personal physician revises form with patient upon change of patient condition or choices annually

14. POLST paradigm Physician Orders on Life Sustaining Treatment Orders cross institutional boundaries home, assisted living, skilled nursing facility EMS pre-hospital Hospital emergency department & inpatient POLST in Action in Oregon (video) http://www.youtube.com/watch?v=CtrrnAJfT2s&context=C3f17b7bADOEgsToPDskJZLOgVI-NCrNBJSeCyi--I

15. Oregon POLST Form & Process -1991 -Bright Pink -Legally binding for EMS -Valid across institutional boundaries

16. SC EMS DNR Form & Process -Physician order -Legally binding for EMS -Valid only pre-hospital

17. Developing Programs National POLST Paradigm Programs Endorsed Programs No Program (Contacts) *As of February 2012

18. POLST: POST in SC Physician Orders on Scope of Treatment SCC-CSI organizational home for POST SC POST form - near ready for adoption. DHEC - ready to authorize POST pilots Greenville & Charleston MUSC Medical Executive Committee endorses CHARLESTON PILOT OF POST  collaborative initiative with MUSC & Roper

19. POLST: POST in SC Physician Orders on Scope of Treatment SCMA annual meeting, April 2012 resolution endorsing POST being introduced

20. Questions: clinical policy C-169 or POST Please contact: Walter Limehouse MD MA limehouw@musc.edu