Compassionate Patient Centered End of Life Care POLST for Alaska - - PowerPoint PPT Presentation

Compassionate Patient‐Centered End of Life Care

POLST for Alaska

IREMS – Fairbanks – 2016

Special Thanks

Mark Miller Ron Quinsey Ken Zafren David Rockney & IREMS

 DNR, full treatment  66 y/o woman with chest pain, SOB and

diaphoresis

 Vitals: P 110, RR 30, O2 97% RA, T 37 C, BP 130/70  Patient was given O2, aspirin and nitro en route  Pre‐hospital EKG shows acute STEMI  Abruptly the patient becomes unresponsive and

develops VT/VF arrest

 What is the patient’s code status?

• A. DNR
• B. Full Code
• C. Unsure

 Intervention decision:

• A. defibrillate
• B. Do not defibrillate
• C. Unsure

 DNR, limited treatment  70 y/o man w/ history of DM, HTN, CAD s/p CABG 10

years ago

 He has chest pain, is clammy and in mild distress  Vitals: T 36 C, P 60, BP 100/60, RR 22, O2 98% RA  Patient abruptly becomes unresponsive w/o pulses,

monitor shows VF

 What is the patient’s code status?

• A. DNR
• B. Full Code
• C. Unsure

 Intervention decision:

• A. defibrillate
• B. Do not defibrillate
• C. Unsure

 DNR, comfort measures only  52 y/o male w/ chest pain, SOB, diaphoresis  Vitals: P 110, RR 30, O2 97% RA, T 37 C, BP 130/70  Patient is given O2, aspirin and nitro en route  EKG shows acute STEMI  Abruptly he becomes unresponsive and develops

respiratory arrest in back of the ambulance

 What is the patient’s code status?

• A. DNR
• B. Full Code
• C. Unsure

 Intervention decision:

• A. Intubate
• B. Do not intubate
• C. Unsure

 Background – End of Life Care  POLST vs Advanced Directive vs Comfort One  Alaska’s Unique Challenges  History of the POLST  Central role of EMS – lessons from other States  Discuss the POLST for Alaska  Your input, suggestions, feedback  Next Steps

EMS

Dignity Prehospital Patient‐Centered

 Of people > 65%,

1/3 have a living will

• And health care

providers (Physicians, APPs, Paramedics, and EMTs) are undertrained

90% 90%

0% 25% 50% 75% 100%

Little/no knowledge of palliative care Would want palliative care

American adults

$170,000,000,000

155,000

One in Three

‐

Largest state in USA

‐

Juneau, not accessible by car

‐

48th most populous state in the US

‐

One third of people live rurally

‐

70% of AK is not accessible by road

‐

80% of physicians are near Anchorage

‐

Just 300 physicians for the rest of AK’s are sprinkled across 600,000+ sq mi

‐

EMS accesses every region of the state via road, boat, air

‐

$25,000‐$100,000 per fixed‐wing transfer



Patients endure unnecessary intervention, suffering, and transport



Alaska incurs avoidable costs of air medevac and subsequent care

Cost of Air Transfer $85,000 Avg LOS 5 Family support 4004 ppl x $100/d Health costs per day $7,000 Cost of One Transfer $122,000 Cost to Norton Sound $48,678,000 Cost to Alaska $244,000,000 Percentage Inappropriate 25%

Potential savings $61,000,000

Percent of Budget State Healthcare budget $2,500,000,000 2% State Traffic budget $600,000,000 10%

Alaska EMS budget $200,000,000

31%

 Should be completed by all adults > 18

 Two types:

• LIVING WILL – identifies types of treatment a patient wants

if terminally ill or in a vegetative state and lack decision‐ making capacity

• HEALTH CARE PROXY ‐ identifies a surrogate to make

decisions when the patient lacks decision‐making capacity

Launched in 1996 Conveys DNR wishes Form + wallet card signed by patient and physician Bracelets must be purchased  $25‐35

1)

Allow terminally ill patients to maintain agency over their end‐of‐life wishes

2)

Alert health care providers of these wishes. Clinical scope focuses exclusively on cardiopulmonary resuscitation (CPR)

In a terminally ill patient the attempts are highly morbid and rarely effective at restoring signs of life

May Provide:

Suctioning O2 Positions of comfort Emotional support Contacting hospice/home health/physician Providing pain medication (if advanced life support personnel with standing

• rders)

Should Not:

Use advanced airway devices Initiate cardiac monitoring Administer cardiac resuscitation drugs Defibrillate Provide ventilatory support

DNR status is not predictive of other End‐of‐Life preferences. Thus, the form is inadequate.

• A patient’s goals of care
• End of life decisions
• Clinical context (past medical history)
• Specific care issues
• Endotracheal intubation
• Mechanical ventilation
• Artificial feeding
• Central or peripheral venous access
• Antibiotics
• Transport
• Etc

 Starting to destigmatize palliative care / DNR  Introducing End‐of‐Life Care to the Prehospital arena  Relationship with the EMS Unit  Help honor wishes of people preferring to be DNR

 Enrollment requires a visit and discussion

between a patient and his or her physician

 Then completion of significant paperwork

• Shortage of physicians in rural areas limited
• pportunities for expansion

 Upon enrollment, the patient is given the

• riginal enrollment form and a wallet card
• Optional bracelet purchase
• Few dozen have purchased these

 There is no Alaska State Registry to rapidly

determine if a critically ill patient is enrolled

• Lengthy and costly

transports

• Excessive and undesired

treatments

• Large burden of psychosocial

stress as a result of uncertainty about a patient’s wishes and goals of care

• For families
• For providers



Limited clinical scope



The form is cumbersome and not intuitive for patients or providers



The DNR order is frequently misunderstood by providers and patients



There is no clear relationship to the MOST form



Requiring an MD rather than PA or NP to complete the form limits its scalability



No tracking of enrollment data. No State Registry.

It is difficult and sometimes impossible for pre‐hospital paramedics or EMTs to determine the wishes of a critically ill patient.

 Expand clinical scope to include other immediate life saving

attempts & comfort‐preserving measures

 Adjust language from DNR to DNAR (do not attempt

resuscitation)

 Integrated form with the best of MOST and Comfort One  Centralized registry that is accessible by providers in the field  Completed by MD, PA, or NP with patient or their surrogate  Continue EMS‐led distribution  Introduce tracking mechanism

An opportunity and imperative exists to use this legacy to dramatically expand the scope and impact of patient‐directed care.

 Implementation of POLST program  Decisions about hospital transfer  Decisions about treatments during transport

Then why not – for the first time – a robust opportunity to help shape the form and the process?

Comfort One MOST Form Other States’ Strategies

Paramedics, EMTs Physicians, Nurses Administrators, Politicians Community / Tribal leaders

Need  Design  Development Implementation

Iterative terative Process Process

 Robustness and reach of Emergency

Medical Services (EMS) in Alaska means that many numbers of patients receive a significant portion of their medical care

• utside of the hospital through

paramedics, emergency medical technicians (EMTs) and community health aides.

 Comfort One is a known program because

it is disseminated through the EMS Unit



Alaska is need of a comprehensive end‐of‐life care plan



Pre‐hospital engagement is critical across the largest and most remote state in the United States



Usability depends on Alaska‐specific features, such as a focus on transport



Collaboration across multiple health specialties is imperative



Form must be compatible with other states, especially in referral network



Scalability and sustainability depends EMS playing a central role

 An approach to end‐of‐life planning emphasizing:

• Conversations between patients, physicians and loved ones
• Shared decision‐making about end of life care
• Ensuring patient wishes are honored

 POLST = an actionable medical order

• Ensures that patients receive what they want
• Decreases the frequency of medical errors

Not for everyone

“progressive chronic illness or frailty, in whom it would not be surprising if they died suddenly within a year”

ADVANCE DIRECTIVE

• Legal document
• Completed by patient
• Anyone 18 and older
• Instructions

for future treatment

• Does not guide

Emergency Medical Personnel

POLST

• Medical orders
• Completed by Provider after

conversation w/ patient

• Persons with serious illness — at

any age

• Medical orders

for current treatment

• Guides actions by Emergency

Medical Personnel

 During emergencies, EMS personnel cannot

follow requests from surrogates, interpret advance directives, and they generally do not have time to identify and call the patient’s HCP to ask for orders. POLST form is brightly colored and included in a patient’s medical record so is easily located

 POLST form represents a DNR order  This is not necessarily true, and each form must be reviewed in order to

determine the specific wishes of each patient.

 A DNR order implies that a patient does not want treatment.  The decision to perform cardiopulmonary resuscitation (CPR) is just one of the

important decisions relating to end of life care, and DNR does not mean do not treat (DNT).

 A well‐designed POLST form can make this point very clear.  One particular challenge in Alaska is that Comfort One is limited in its scope to

address only the issue of DNR

 A slightly more nuanced point of confusion is about whether or not

there is a difference between withholding and discontinuing life‐ sustaining treatments.

 There are no ethical or legal distinctions Each of these possible misunderstandings can be addressed through a well‐designed form and educational efforts.

Having a POLST means providers will ignore my needs

‐ This is not true. ‐ Individuals with POLST orders for full

treatment receive the same number of interventions as those without a POLST

‐ The POLST does not result in worse care. It

results in personalized care.

 Originated in Oregon in 1991  Advance directives were not sufficient to honor seriously

ill and frail patient preferences for end‐of‐life care

 Several states quickly followed Oregon’s lead:

• New York, Pennsylvania, Washington, West Virginia, and

Wisconsin

• Sep 2004 ‐The National POLST Paradigm Task Force (NPPTF)

was founded to establish quality standards for POLST forms and to assist states in developing such programs

A) CPR or Not B) Medical interventions (full, limited, or comfort only) C) Specific wishes

 Hospital transfers  Antibiotics  Artificial nutrition and hydration  Others…

Valid for care across all settings: home, nursing home, hospital, outpatient clinic, EMS

Cardiac arrests – 93% of EMTs found the POLST form helpful Non‐cardiac arrests – 63% found it helpful Most forms are not designed by providers

Schmidt et al, “The POLST Program: Oregon EMTs Practical Experiences and Attitudes” J Am Geriatr Soc. 2004 Sep;52(9):1430‐4.

 Medical orders  Treatment hierarchy

• Starting with DNR or CPR
• Followed by if patient not in

cardiac arrest

 Two essential criteria

• Fidelity to patient preferences
• Clarity for ease of comprehension

POLST  Paradigm Shift From a legal transaction to portable, goal‐oriented end‐of‐life treatment

 Given transfer patterns to WA, inter‐state compatibility is

important

 There is a stronger national movement and support for POLST

vs others

 All immediately important information visible on one page  Patient goals and/or values must be prominent  AK requires more clarity and emphasis on transfer preferences

Highlights



Easy to follow



All key information on first page



EMS checklist reminder



Clarity about wishes



Clarity about who signed it Still to Add



Registry Info Important Note



Photocopies are valid

Highlights



Easy to update



Instructions for Health Professionals



Contact info of patient



Updated



Transfer facilities



Change in condition / prognosis

 Of patients desiring CPR: 84% received it  Of patients preferring DNR: 22% received CPR

 Form transfers with the patient  Communicates care preferences across different health care settings  Primarily used by patients with advanced, progressive, chronic illness  Clarifies patient’s treatment choices with medical orders  Completed by MD, PA, or NP  Designed by clinical providers  2,000 – 4,000 PTs receiving compassionate patient‐directed care  Millions in savings $$$

 Take a Few Minutes to Review  Use the papers to note your comments and

suggestions

• To the POLST Form
• About the Implementation Process



Online & In‐Person



EMS personnel



MDs, NPs, PAs

 Legislation change

• White paper in progress

 EMS leadership of process

New York



Electronic registry web‐based



Allows for electronic signature



Training / guideline resources available



Takes the entire process online May not be most suitable for Alaska Oregon



EMS, Emergency Departments, and ICUs have 24/7/365 access to the Oregon POLST Registry



877‐367‐7657



Takes 1 minute per call



Opt‐out

Alaska



Borrow features of existing programs



Customized for Alaska



Point‐of‐care app that does not require internet connectivity 100% of the time

Meant to keep it on fridge, but

• ften people don’t like to

Lessons from Surgery (safe surgery checklist) Lessons from All Procedural Fields (Time Out)

Resuscitation is a procedure (Resuscitation Pause)

 Form finalization  Legislation change  Training (online, in‐person) 

EMS personnel



MDs, NPs, PAs

 Form distribution  Digital registry

 DNR, full treatment  87 y/o man with sudden SOB. He is agitated,

confused and in severe respiratory distress

 Vitals: P 130, RR 50, BP 70/50, T 37 C, O2 78% on

non‐rebreather

 Abruptly the patient goes into respiratory arrest

 What is the patient’s code status?

• A. DNR
• B. Full Code
• C. Unsure

 Intervention decision:

• A. Intubate
• B. Do not intubate
• C. Unsure

 DNR, full treatment  66 y/o woman w/ chest pain, SOB, diaphoresis  Vitals: P 110, RR 30, O2 97% RA, T 37 C, BP

130/70

 She receives O2, aspirin and nitro en route  Prehospital EKG shows acute STEMI  Abruptly the patient becomes unresponsive

and develops VT/VF arrest

 What is the patient’s code status?

• A. DNR
• B. Full Code
• C. Unsure

 Intervention decision:

• A. defibrillate
• B. Do not defibrillate
• C. Unsure

 CPR, full treatment  90 y/o man w/ sudden SOB  He is agitated, confused, and in severe

respiratory distress

 Vitals: P120, RR 46, BP 84/60, T 37 C, O2 72% on

nonrebreather

 Abruptly, the patient goes into respiratory

arrest

 What is the patient’s code status?

• A. DNR
• B. Full Code
• C. Unsure

 Intervention decision:

• A. Intubate
• B. Do not intubate
• C. Unsure

 EoL care is important, and a big issue  Goals of care are rarely known and sometimes

impossible to follow

 A POLST strategy can ensure patient‐centered

compassionate care across hospital settings

 Almost all POLSTs are not designed by providers

• Alaska’s will be different  better (especially with your input!)

 EMS is critical in the implementation and success of the

program

 The future may also include a real‐time digital registry  Consider trying a resuscitation pause at your next 911

call

Special Thanks

Mark Miller Ron Quinsey Ken Zafren David Rockney & IREMS

For life and death are one, even as the river and the sea are one.

‐ Kahlil Gibran

For life and death are one, even as the river and the sea are one.

‐ Kahlil Gibran