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

Patient ‐ Centered Dignity EMS Prehospital

 Of people > 65%, 1/3 have a living will  And health care providers (Physicians, APPs, Paramedics, and EMTs) are undertrained

American adults 90% 90% 100% 75% 50% 25% 0% Little/no knowledge of Would want palliative care palliative care

$170,000,000,000 155,000 One in Three

Largest state in USA ‐ Juneau, not accessible by car ‐ 48 th 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 400 4 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% 31% Alaska EMS budget $200,000,000

 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

Allow terminally ill patients to maintain agency over 1) their end ‐ of ‐ life wishes Alert health care providers of these wishes. 2) 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

Should Not: May Provide:  Suctioning  Use advanced airway devices  O2  Initiate cardiac monitoring  Positions of comfort  Administer cardiac  Emotional support resuscitation drugs  Contacting hospice/home health/physician  Defibrillate  Providing pain medication  Provide ventilatory support  (if advanced life support personnel with standing orders)

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

 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  Lengthy and costly transports  Shortage of physicians in rural areas limited opportunities for expansion  Excessive and undesired  Upon enrollment, the patient is given the treatments original enrollment form and a wallet card  Large burden of psychosocial  Optional bracelet purchase stress as a result of uncertainty about a patient’s  Few dozen have purchased these wishes and goals of care  There is no Alaska State Registry to rapidly  determine if a critically ill patient is enrolled 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.

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

 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?

Need  Design  Development  Implementation Iterative terative Paramedics, EMTs Comfort One Process Process Physicians, Nurses MOST Form Administrators, Politicians Other States’ Strategies Community / Tribal leaders

 Robustness and reach of Emergency Medical Services (EMS) in Alaska means that many numbers of patients receive a significant portion of their medical care outside 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”

POLST ADVANCE DIRECTIVE  Medical orders  Legal document  Completed by Provider after  Completed by patient conversation w/ patient  Anyone 18 and older  Persons with serious illness — at any age  Instructions  Medical orders for future treatment for current treatment  Does not guide  Guides actions by Emergency Emergency Medical Medical Personnel 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