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Policy Issue Identification: Resolving Conflicts over Life- Sustaining Treatment in Virginia Dea Mahanes, MSN, RN, CCNS, FNCS NURS638 Health Policy, Leadership & Advocacy Virginia Commonwealth University Learning Objectives Understand

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Policy Issue Identification: Resolving Conflicts over Life- Sustaining Treatment in Virginia

Dea Mahanes, MSN, RN, CCNS, FNCS NURS638 Health Policy, Leadership & Advocacy Virginia Commonwealth University

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Learning Objectives

  • Understand current Virginia law pertaining to

resolution of life-sustaining treatment conflicts.

  • Analyze the impact of policy action or inaction from

the perspective of the patient, surrogate, and clinician.

  • Apply Kingdon’s model to policy actions related to

life-sustaining treatment conflicts in Virginia.

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Health Policy Issue Introduction

  • Clinician-surrogate conflict over life-sustaining

treatment

  • Life-sustaining treatment (LST), also referred

to as life-sustaining care: mechanical/artificial means to sustain, restore or replace a spontaneous vital function (paraphrased from the Va. Code Ann. §54.1-2990, 2009)

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Health Policy Issue Introduction

  • Overview of end-of-life care in the ICU

– 65% of deaths preceded by decision to withhold or withdraw LST (Lobo et al., 2017) – 33-38% of patients receive non-beneficial treatments (Cardona-Morrell et al., 2016)

  • Disagreement about prognosis/treatment common

(Pope & Kemmerling, 2016)

– Common cause of moral distress (Whitehead, Herbertson, Hamric, Epstein, & Fisher, 2015; Hamric & Epstein, 2017)

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Health Policy Issue Introduction

  • Multi-society position statement: responding to

requests for inappropriate or potentially inappropriate treatment (Bosslet et al., 2015)

– Seven-step process to resolve conflicts

  • SCCM policy statement: defining futile or potentially

inappropriate treatments (Kon et al., 2016)

– No reasonable expectation of improvement that would allow patient to survive outside of the acute care setting,

  • r perceive the benefits of treatment
  • “Clinicians should recognize the limits of prognostication…”
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Health Policy Issue Introduction

  • Code of Virginia, §54.1-2990 (2009)

– Clinicians are not obligated to provide treatment that is medically or ethically inappropriate – Care must be continued for a period of 14 days to enable the patient’s agent to seek transfer to another provider or facility – Does not address actions to be taken at the end of the 14-day period if no provider or facility has been located

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Health Policy Issue Introduction

  • Studied by Virginia Joint Commission on

Health Care in 2016 and 2017: Life-Sustaining Treatment Work Group (Mitchell, 2017)

– Survey of health systems in Virginia – Policy options:

  • No action
  • Introduce legislation to amend §54.1-2990 (drafted

language)

– Public comment period through October 12th

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Health Policy Issue Introduction:

Draft Amendment (Mitchell, 2017)

  • Allows for cessation of medically or ethically

inappropriate treatments after 14 days

– Special considerations for artificial hydration and nutrition

  • Requires hospitals to enact policies that outline

actions to be taken in the event of treatment conflict

– Second medical opinion – Interdisciplinary medical review committee with

  • pportunity for the patient/surrogate to participate

– Inclusion of decision (with explanation) in medical record

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Health Policy Issue’s Relevance to Quality & Safety

  • Population health

– Families as a vulnerable population

  • Experience of care

– Communication – Transparency

  • Cost

– Futile care cost estimate

  • f $4004/day (Huynh et

al., 2013)

The Triple Aim Berwick, Nolan, & Whittington, 2008

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Health Policy Issue’s Relevance to Quality & Safety

  • Population health,

experience of care, cost plus…

  • High quality health

care includes a focus

  • n clinicians

– Meaning in work – Avoiding burnout

Population Health

Cost Clinician Health Experience

  • f Care

The Quadruple Aim

Bodenheimer & Sinsky, 2014. Sikka, Morath, & Leape 2015.

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Implication of Policy Action/Inaction

  • Current Virginia statistics (Mitchell, 2017)

– 56% of health systems surveyed have a written process for managing intractable treatment conflict – 7 of 8 health systems without a written process believe a process is needed

  • 5 of 7 identified lack of legislative clarity as a barrier
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Implication of Policy Action:

Amendment Proposed and Passed

  • Patients

– Protections against discrimination (Mitchell, 2017)

  • Surrogate

– Clear process with opportunity for participation (Mitchell, 2017) – Potential relief at removal of decision-making pressures (Fine & Mayo, 2003)

  • Clinicians

– Legislative protections if process followed (Mitchell, 2017) – Impact on moral distress

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Implication of Policy Inaction:

State Statute Remains Unchanged

  • Continue current practices

– Variability for patients, surrogates, and clinicians based on health system/organization

  • Lack of clarity about actions to take after 14-day period
  • Current Virginia statistics (Mitchell, 2017)

– 40 cases over 12 months in hospitals with a policy

  • On average (by health system), 5% cases resulted in

withdrawal/withholding over objection

– Hospitals without a policy estimate 45-90 cases/yr

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Theoretical Frame of Reference

Overview of the Kingdon Model (Kingdon, 1995)

  • Information indicates the existence
  • f a problem

Problem Stream

  • Available solutions

Policy Stream

  • Policy-makers/administration have

motive and opportunity to act

Political Stream

Window of Opportunity

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Integrating Policy and Theory:

Kingdon and Treatment Conflict in Virginia

  • Treatment conflict
  • Common and impactful
  • Lack of legislative clarity

Problem Stream

  • National guidance documents
  • Bosslet et al., 2015.
  • Kon et al., 2016.

Policy Stream

  • November Elections
  • House of Delegates
  • Executive Branch

Political Stream

Window of Opportunity

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Learning Objectives

  • Understand current Virginia law pertaining to

resolution of life-sustaining treatment conflicts.

  • Analyze the impact of policy action or inaction from

the perspective of the patient, surrogate, and clinician.

  • Apply Kingdon’s model to policy actions related to

life-sustaining treatment conflicts in Virginia.

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References

  • Berwick, D. M., Nolan, T. W., & Whittington, J. (2008). The triple aim: Care, health, and cost.

Health Affairs (Project Hope), 27(3), 759-769. doi:10.1377/hlthaff.27.3.759

  • Bodenheimer, T., & Sinsky, C. (2014). From triple to quadruple aim: Care of the patient

requires care of the provider. Annals of Family Medicine, 12(6), 573-576. doi:10.1370/afm.1713

  • Bosslet, G. T., Pope, T. M., Rubenfeld, G. D., Lo, B., Truog, R. D., Rushton, C. H., . . . Society of

Critical Care. (2015). An official ATS/AACN/ACCP/ESICM/SCCM policy statement: Responding to requests for potentially inappropriate treatments in intensive care units. American Journal

  • f Respiratory and Critical Care Medicine, 191(11), 1318-1330. doi:10.1164/rccm.201505-

0924ST

  • Cardona-Morrell, M., Kim, J., Turner, R. M., Anstey, M., Mitchell, I. A., & Hillman, K. (2016).

Non-beneficial treatments in hospital at the end of life: A systematic review on extent of the

  • problem. International Journal for Quality in Health Care : Journal of the International Society

for Quality in Health Care, 28(4), 456-469. doi:10.1093/intqhc/mzw060

  • Fine, R. L., & Mayo, T. W. (2003). Resolution of futility by due process: Early experience with

the Texas advance directives act. Annals of Internal Medicine, 138(9), 743-746. doi:200305060-00011

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References

  • Hamric, A. B., & Epstein, E. G. (2017). A health system-wide moral distress consultation

service: Development and evaluation. HEC Forum : An Interdisciplinary Journal on Hospitals' Ethical and Legal Issues, doi:10.1007/s10730-016-9315-y

  • Huynh, T. N., Kleerup, E. C., Wiley, J. F., Savitsky, T. D., Guse, D., Garber, B. J., & Wenger, N. S.

(2013). The frequency and cost of treatment perceived to be futile in critical care. JAMA Internal Medicine, 173(20), 1887-1894. doi:10.1001/jamainternmed.2013.10261

  • Kingdon, J. W. (1995). The policy window, and joining the streams. In Agendas, alternatives,

and public policies (2nd Ed., pp. 165-195). New York: Longman.

  • Kon, A. A., Shepard, E. K., Sederstrom, N. O., Swoboda, S. M., Marshall, M. F., Birriel, B., &

Rincon, F. (2016). Defining futile and potentially inappropriate interventions: A policy statement from the society of critical care medicine ethics committee. Critical Care Medicine, 44(9), 1769-1774. doi:10.1097/CCM.0000000000001965

  • Lobo, S. M., De Simoni, F. H. B., Jakob, S. M., Estella, A., Vadi, S., Bluethgen, A., . . . ICON
  • investigators. (2017). Decision-making on withholding or withdrawing life support in the ICU:

A worldwide perspective. Chest, 152(2), 321-329. doi:S0012-3692(17)30820-6

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References

  • Mitchell, A. (September 19, 2017). Life-sustaining treatment guidelines work group – final

report to the Joint Commission on Health Care. Retrieved from http://jchc.virginia.gov/2.%20Life%20Sustaining%20Treatment%20Guidelines%20- %20final%20report%20-%20revised%20-%209.20.17.pdf

  • Pope, T. M., & Kemmerling, K. (2016). Legal briefing: Stopping nonbeneficial life-sustaining

treatment without consent. The Journal of Clinical Ethics, 27(3), 254-264. doi:2016273254

  • Sikka, R., Morath, J. M., & Leape, L. (2015). The quadruple aim: Care, health, cost and

meaning in work. BMJ Quality & Safety, 24(10), 608-610. doi:10.1136/bmjqs-2015-004160

  • Va. Code Ann. §54.1-2990, 2009, Retrieved from

https://law.lis.virginia.gov/vacode/title54.1/chapter29/section54.1-2990/

  • Whitehead, P. B., Herbertson, R. K., Hamric, A. B., Epstein, E. G., & Fisher, J. M. (2015). Moral

distress among healthcare professionals: Report of an institution-wide survey. Journal of Nursing Scholarship : An Official Publication of Sigma Theta Tau International Honor Society

  • f Nursing / Sigma Theta Tau, 47(2), 117-125. doi:10.1111/jnu.12115
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Questions