2. “Death is an inevitable
aspect of the human
condition.
Dying badly is not.”
Jennings, et al, 2003
3. Need for more specific advance care planning
at the end of life.
The process of making POST available in
Virginia as a communication tool for end of
life care wishes.
How POST is affecting end of life care at the
bedside.
Resources
6. Advance directives not documented
DNR order not communicated in transfer
Fragmentation in care (2 hospitals)
Overtreatment against patient’s wishes
Unnecessary pain and suffering
System-wide failure to respect pt’s wishes
Failure to plan ahead for contingencies
No system for transfer of plan
7. In the case of a person with a terminal or
serious progressive illness, is having a living
will and durable medical power of attorney
enough ?
11. Name a Healthcare
Agent
Prepare for sudden
injury or event
Complete basic
Advance Directive
Source: Carol Wilson, Riverside Health System;
Used with permission
12. Understand potential
complications and
treatment options
Consider benefits and
burdens of end of life
treatments
Discuss preferences
with family
Make Advance
Directive more specific
Re-evaluate goals with
changes in condition
Source: Carol Wilson, Riverside Health System;
Used with permission
13. No longer
hypothetical
Express preferences
for treatment as
medical orders
Use POST form in
communities where
it is accepted
Source: Carol Wilson, Riverside Health System;
Used with permission
14. For every adult
Requires decisions
about myriad of
future treatments
Requires
interpretation
Needs to be
retrieved
For the seriously ill
Decisions among
presented options
Medical orders
which turn a
patient’s values
into action
Follows patient
across settings of
care on consistent
document*Fagerlin & Schneider. Enough: The Failure of the Living Will.
Hastings Center Report 2004;34:30-42.
15. No specific end of life care orders means
patients want full interventions.
◦ Maybe, maybe not . . .
◦ And what’s the default if the patient can’t tell you?
A DNR order means a patient doesn’t want
more than comfort measures.
16. DNR Status is not a predictor of the care
patients wish for at the end of life—many
with DNR chose limited or full interventions
as well as artificial nutrition.
PO(L)ST is a neutral form—allows patients to
have or limit treatment.
PO(L)ST reduces making assumptions based
on DNR status alone.
Fromme, E.K. Zive, D., Schmidt, T.A., Olszewski, E. & Tolle, S.W. (2012). POLST Registry, Do-Not-Resuscitate orders and other patient
treatment preferences. Journal of the American Medical Association, 307(1), 34-35.
17.
18.
19. 2007 2008 2009 2010 2011 2012 2013
History of POST in Virginia
IDEA +1 Local Pilot Project State Stakeholders
Grant & In-Kind Support
+ =
Virginia POST
Collaborative
&
13 Regional POST
Programs
20.
21.
22.
23.
24.
25.
26. Clear Message: Who is appropriate for POST?
Becoming a participating pilot project region.
Advance Care Planning Facilitator Training
PCP Training
End-User Training
Public Education
27. POST is for:
Seriously ill patients*
Terminally ill patients
Those with advanced frailty
Gives options to limit or have
care
Voluntary
Can be revoked or changed
Comfort measures always offered
* chronic, progressive disease/s
28. ◦ Ongoing training, mentoring and
support
◦ POST Pilot Project Training Webpage
◦ Training webinars and
presentations
◦ One-on-one consultation
29. Careful discussions that elicit care
preferences ARE the main thing.
Who will facilitate these discussions ?
◦ Non-physician POST ACPF’s must be certified in
order to have conversation and assist in POST form
completion
30. Designated ACPF training model for Virginia
Fundraising from state and regional funding
sources (including GTE) for training process.
Pre-workshop online learning modules + all-day
workshop.
15 training sessions with nearly 450 facilitators
trained from multiple disciplines
31. Problem: Few physicians have time to
participate in RC Training
GTE Grant: Develop, pilot and refine a one-
hour training for physicians caring for POST-
appropriate patients.
Theme: Promote It, Sign It, Honor It
Presentations scheduled for May and June
2013
CME credits granted
Future: Conduct train the trainer so that
regional pilots can host these trainings.
32.
33. For care providers who are likely to come in
contact with a patient with a POST form.
Participating hospitals, nursing care
facilities, hospices, EMS, and other care
settings.
GTE Funding to refine template presentations
in multiple formats:
◦ Live presentations
◦ Online self-paced module
Thousands of end-users trained in pilot
regions.
34. Primarily limited to pilot project regions.
Growing interest and multiple requests from
patients/families
Virginia POST Website:
◦ Funding from National POLST, GTE and a hospital
system.
◦ Full website up and running by Summer 2013
35. Skilled Trained
Facilitators
Laws, Statutes, Regulations
Uniform Policies, Procedures, Standards
POST Form
Can Care Settings Provide
Competent,
Compassionate
Palliative Care?
Collaborative
Stakeholders
and
Coalitions
Resources
Webpage and
Communication Plan
Physician Support
Advocacy Plan
37. Began in December 2009
Most ACP discussions and POST forms were done
in nursing care facilities
QI data collected from medical records of nearly
100 residents/patients with POST forms:
◦ 98% congruency between orders written and care
delivered
38. 9 transfers
◦ 1 to ALF
◦ 4 to ED (2 for foley insertion, 1 for GI bleed; other
unknown)
◦ 2 admitted to hospital (1 died in hospital, other
returned to facility)
◦ 2 transferred to VAMC Palliative Care unit.
Place of Death: Only 1 patient with a POST form died in
an acute care unit in the hospital
Residents who died without POST form: 25 % died in
acute care setting in hospital
Implications to hospitals/facilities for readmission
scrutiny
39.
40. PO(L)ST is achieving its goal of honoring tx
preferences of those with advanced illness or
frailty.
Plus----PO(L)ST serves as an ACP
conversation catalyst”
41. Review:
◦ Where POST is in Virginia
◦ Contacting your Region’s POST Pilot Project
Coordinator
No Pilot in Your Area?
◦ Contact Laura Pole (Lpchef@earthlink.net) for
guidelines on implementing POST in your
community
42. National POLST Paradigm: www.polst.org
Virginia POST Collaborative:
www.virginiapost.org
• National Hospice Foundation:
www.hospiceinfo.org
• National Hospice and Palliative Care
Organization: www.nhpco.org
• Palliative Care Partnership of the Roanoke
Valley: www.pcprv.org
• “Hard Choices for Loving People”
by Hank Dunn
43. National POLST Paradigm: www.polst.org
VHHA:
http://www.vhha.com/healthcaredecisionmaking.
html
NHPCO: Caring Connections:
http://www.caringinfo.org
National Health Care Decisions Day:
http://www.nhdd.org/
44. POST provides a better means than AD alone to
identify and respect patients’ wishes
POST completion will improve end-of-life care
throughout the system
Use of POST requires communication to make it
work in your community
Local, Regional and Statewide collaboration is
pivotal to making POST available as a
uniform, portable and legal document and process.
Perhaps the most revealing data on the POLST Paradigm were presented at the 2012 National POLST Conference. Data from Oregon assuage the unfounded concern of some that the PO(L)ST form is biased toward steering patients to limit care. Researchers, analyzing all active forms signed and submitted from December 2009 through December 2010, investigated the populations using the POLST registry and their preferences for treatment, and determined the prevalence of each POLST order. The researchers then calculated the probability of other specific end-of-life care orders, depending on whether patients had a DNR order or an attempt CPR order. There was significant heterogeneity in orders, meaning that many patients, including those who did not want to be resuscitated, chose to have additional limited or full interventions and/or tube feedings. Clearly, the POLST form is a neutral form and meets the intent of honoring the freedom of persons with advanced illness or frailty to have or limit treatment. Another critical implication of these results is that a DNR order alone is a poor predictor of the medical care that dying patients want. It is not uncommon for health care professionals to assume that patients who do not want to be resuscitated would choose to have only comfort measures
Mrs. West was a 92 year-old widow who lived on a long-term care unit at a large nursing care facility in Virginia. She had chronic renal disease, heart failure, diabetes, hypertension, and a recent stroke. Her heart failure and renal disease were progressing, making it clear that she was not likely to live more than a year. A social worker at this facility, trained as a POST Advance Care Planning Facilitator, informed Mrs. West and her daughter that they could avail themselves of a process of advance care planning that would result in a doctor’s order sheet that would serve as a communication tool both within and outside the facility. The daughter, who had Mrs. West’s medical power of attorney, was particularly interested because her brother tended to press their mother to have more interventions than Mrs. West wished. In the POST Advance Care Planning session, Mrs. West said she did not want to be resuscitated when she stopped breathing and her heart stopped beating. She added that, in addition to aggressive comfort measures, she wanted some limited medical interventions, such as cardiac monitoring, less invasive airway support, and transfer to the hospital, if indicated, but asked that health care providers avoid putting her in the ICU. Mrs. West’s primary care physician reviewed the POST orders with Mrs. West and her daughter and signed the form to activate the orders. Shortly thereafter, Mrs. West developed fluid retention in her abdomen and her lower extremities. Her physician, not certain if this was due to her known chronic illnesses, recommended sending her to the hospital emergency department (ED) to be evaluated. The daughter did not want her mother to go to the hospital, but Mrs. West consented to her doctor’s recommendation. She was admitted to the hospital after evaluation in the ED. The hospitalist urged her to go on dialysis. Mrs. West adamantly refused but the hospitalist persisted. The daughter called the nursing home social worker who supported their decision and encouraged them to be firm and clear with the hospitalist. The daughter repeatedly assured the hospitalist that they’d thought this through in the POST advance care planning process. Mrs. West summed it up, “I’m 92 years old. I’ve lived a long and good life. I don’t want to spend the rest of my life dependent on being hooked up to a dialysis machine. If this is all you have to offer me, then I don’t need to be at the hospital. I want to go back to the nursing home where I live.” Mrs. West returned to the nursing home two days later and the POST form was reviewed, voided, and a new one completed with the change from “Limited Medical Interventions" to “Comfort Measures.” Mrs. West was moved to a palliative care room and hospice became involved. She died comfortably three weeks later. Mrs. West’s case illustrates how proactively and effectively the POST Advance Care Planning discussion helped her think through, identify, and communicate her values and goals of care to her family and to those providing her medical care. It beautifully highlights that the advance care planning process is dynamic and fluid. As a person’s medical condition changes, it’s necessary to review the POST form and see if the person’s wishes for treatment have changed.