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Palliation e.hart
1. Increasing Appropriate Hospice and
Palliative Services through
Improved Communication and
Documentation of Patients’ Wishes
Elizabeth Balsam Hart, MD
MaineGeneral Health
With support from the Practice Change Fellows Program,
the Atlantic Philanthropies and the John A Hartford Foundation
2. “How people die remains in the memories of those
who live on.”
Dame Cicely Saunders
3. 3
Divisions by Health Status in the Population and
Trajectories of Eventually Fatal Chronic Illnesses
Joanne Lynn, MD, MA, MS, Center to Improve Care of the Dying, RAND
Divisions in the Population
Group 1
Group 2
Group 3
“Healthy,” needs
acute and
preventive care
“Chronic, not
“serious”
Chronic,
progressive,
eventually fatal
illness
Major Trajectories near Death
AA
Time
Low
High
FunctionFunction
death
Time
BB
Low
High
Function
deathdeath
CC
TimeTime
LowLow
High
Function
death
4. Advance Care Planning
Often the concerns and wishes we have for end-
of-life care emerge as the situation unfolds, or are
never discussed, rather than making intentional
choices, based on thoughtful discussions in
advance about quality of life, values, risks and
benefits, and goals of care
We often make the most difficult decisions in a
time of crisis, under a shadow of grief, or at a time
when communication between those involved
may be challenging
5. Conversations - not just forms
• Advance Care Planning is …
• “A process of coming to understand, reflect
on, discuss, and plan for a time when you
cannot make your own medical decisions and
are unlikely to recover from your injury or
illness.”
» Making Choices™
» Planning in Advance for Future Healthcare Choices
» Gundersen Lutheran Medical Foundation
6. Purpose of POLST (Physician Orders
for Life-Sustaining Treatment)
To provide a mechanism to communicate
patient preferences for end-of-life
treatment across treatment settings
7. What is POLST ?
• A Set of Actionable Medical Orders
• Can be completed by any healthcare professional, but
must be signed by a licensed physician*
• Complements, but does not replace, advance
directives
• Voluntary use, but provides consistent recognized
document
*In some states a nurse practitioner or physician assistant may sign the POLST form
8. The Surprise Question
• Would you be surprised if your patient
with advanced cancer died in the next
year?”
• If the answer is “No”, likely appropriate
for POLST
• Connections between POLST model and
Cancer Plan Objectives 15.1 – 15.7
Notas do Editor
How many people are in this category? Relying on business data from Franklin Health, at any one time about 1-2 percent of adults under 65 years of age have serious, eventually fatal chronic illness, and about 3-5 percent of those over 65. That’s the rate in cross-section. Over our life-spans, though, about three-quarters of us have a period of being so ill that we cannot take care of ourselves, and that period averages 2-3 years. The patient’s dependency involves family members in care giving; women now spend as much time in eldercare as in care of children. The numbers of persons facing serious chronic illness will at least double over the coming twenty years, as the baby boom encounters old age. Until now, lives with serious chronic illness have been largely invisible: very few evening television stories, for example, include this phase of life. Yet, people with eventually fatal chronic illnesses use substantial resources, often inefficiently, and they and their families are profoundly disappointed with the difficulties they encounter in using the “care system.”
What is life like for people living in that wedge of eventually fatal chronic illness? Our research team started with the considered opinion that most people might follow one of three major courses, or trajectories.
Jama May 14th 2003 Vol 289 page 2389
Functional Decline at End of Life - 15% sudden death
21% cancer and 5% frail
4190 death 20% organ failure 8%frail
frail 20%
other 24%
