A Primer for Home Health Clinicians Advance Care Planning: The Role in Population Health Management...
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A Primer for Home Health Clinicians Advance Care Planning: The Role in Population Health Management Population Health Management is focused on managing
Advance Care Planning: The Role in Population Health Management
Population Health Management is focused on managing patients with
chronic illness in a more proactive, anticipatory manner. Most
chronic illnesses have a predictable trajectory. How do we prepare
patients in a more responsible and sensitive manner to the path
that their illness will most likely take? How can we as home care
providers: a. Engage patients in conversations about their disease
pathway? b. Enpower patients to participate in their careplanning
process?
Slide 4
Could This Happen In Roanoke? Mr. Dehart, a 71 year old patient
with severe COPD and mild dementia, resides at home with his wife.
He develops increasing SOB and his wife calls 911. When EMS
arrives, the adult daughter, visiting from out of town, advises
them the family wants everything done. The wife does not mention
her husbands DDNR. EMS staff, having found the patient
unresponsive, try to intubate him, but cannot. They insert an oral
airway and transport the patient to the ER. Mr. Dehart remains
unresponsive with a RR of 8 and an O 2 sat of 85% despite
supplemental O 2. Pursuant to a chest X- ray, the ER physician
writes, full code for now, status unclear. The staff intubate Mr.
Dehart and transfer him to the intensive care unit.
Slide 5
What Went Wrong?
Slide 6
DDNR order not communicated to EMS and in subsequent transfer.
Advance directive not documented. (Do you think advance directive
would have been followed in this situation if it were documented?)
Family at odds with patients wishes. Lack of communication between
healthcare providers treating clinicians left out of loop. Results
include overtreatment of patient with unnecessary physical
discomfort, costs, and prolonged dying process.
Slide 7
The problem with communication is the illusion that it has been
accomplished. - George Bernard Shaw
Slide 8
Common Issues With Advance Directives Advance Directives (AD)
frequently use statutory language that can be hard to understand.
Healthcare staff trying to assist patients in completing an AD
often focus on how to complete the form, not adequately discussing
the issues at hand. Focus has been more on legal rights and less on
help for patient in making informed decision about his/her
individual care.
Slide 9
Story of Stephanie Martin Glennon January 2013 Stephanies
husband, a physician and internist was diagnosed with metastatic
pancreatic cancer. No one but my husband and I seemed to want to
talk about [that care]. With unwavering support of friends, we were
able to get my husband home only by going rogue [when a] medical
director was resistant to sending him home, and was suggesting yet
more procedures he did not want and could not endure. We took him
home, where he was surrounded by us and friends and other family
members, surrounded by our childrens artwork and pictures and music
and where, for the first time during this ordeal, he encountered no
pain and no nausea and finally was in comfort. He was able to speak
and laugh and reminisce until he slipped into unconsciousness on
his very last day and died peacefully, without medical
interventions he never wanted.
Slide 10
What is POST? A physician order Can be completed by a
non-physician provider such as an NP or PA as well an MD or DO
(Osteopath) Complements, but does not replace, advance directives
Voluntary use Recognized by EMS as a valid DDNR 9
Slide 11
Who Is Eligible For POST? 1. Seriously ill persons, i.e., those
with chronic, progressive disease 2. Terminally ill persons
Slide 12
Conversations that change over time Source: Carol Wilson,
Riverside Health System; Used with permission Healthy Adults:
Emergency Planning People with Progressive Illness: guided planning
End Stage Illness: Physician Orders for Scope of Treatment
Slide 13
Who Is Eligible For POST? Prompt for POST completion: Would I
be surprised if this patient died in the next year?
Slide 14
Living Will vs. POST (Remember: Patients may have both forms.)
Living Will* For every adult regardless of health Decisions about
open- ended myriad of treatments Needs to be retrieved Normally
requires interpretation (*Hastings Center Report 2004; 34: 30 42)
POST For seriously or terminally ill adults Decisions among
presented treatment options Stays with patient Physicians order for
specific treatment(s)
Slide 15
Purpose of POST To provide a mechanism to communicate patients
preferences for end-of-life treatment across treatment settings To
improve implementation of advance care planning 14
Slide 16
Expected Outcomes of Using POST Process Improved continuity of
careForm transferable across treatment settings Clearer
communication of wishes Reduced hospitalization and inappropriate
life- sustaining treatments Fewer EMS transports More accurate
representation of preferences Higher adherence to wishes by medical
professionals.
Slide 17
POST Can Be Completed In Many Settings
Slide 18
The Conversation POST discussions must be facilitated by the
patients physician or a trained Advance Care Planning Facilitator
(ACPF). The facilitator may choose to involve other members of the
patients healthcare team as well. The dialogue may or may not
result in the completion of a POST document, but it does create an
environment of shared and informed decision making for the patient
facing serious illness.
Slide 19
Role of ACP Facilitator 1. Explores patients understanding of
advance care planning and the role of a healthcare representative.
2. Explores understanding of medical condition, including possible
complications that may occur. 3. Provides meaningful context for
decision making through identifying previous key healthcare
experiences, fears & worries, values, and important beliefs. 4.
Explores patients understanding of CPR, comfort care, antibiotics,
artificial nutrition and hydration, etc. 5. Ensures that patients
wishes are clearly documented on transferable form. 6. Develops
list of pertinent questions that may involve physician and
others.
Slide 20
Why an Advance Care Planning Facilitator (ACPF)?
Slide 21
Why an ACPF? Has received training in having discussions with
patients and POAs about preferences for EOL care Training was based
on our POST form The Advance Care Planning process takes about 45
minutes and often involves follow-up and/or additional sessions It
is important that POST form is not just a check off sheet---an ACPF
can make sure people know and understand their options
Slide 22
Who in our family are ACPs? Megan Moore, Hospice Social Worker
Roanoke Debbie Quick-Conner, Hospice Social Worker Roanoke Nicole
Bailey, Home Health Social Worker Tina Smusz, Hospice Medical
Director Lisa Sprinkel, Home Care and Hospice Leigh Faulconer,
Hospice Social Worker NRV Sharon Crane, Hospice Social Worker
NRV
Slide 23
How to Complete a POST Form Must be completed by a physician or
by a non- physician health care professional who has been trained
as a POST Advance Care Planning Facilitator (ACPF). Must be based
on patient/resident preferences Must be signed by an MD or DO Next
form revision (in mid 2013)NPs and PAs will be able to sign
Slide 24
POST Form
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24
Slide 26
25
Slide 27
Section A: Resuscitation Only section applicable to EMS These
orders only apply if a person is pulseless and apneic. This section
does not apply to any other medical circumstances. POST recognized
as a valid Virginia Other DNR When Do Not Attempt Resuscitation is
checked, qualified healthcare personnel are authorized to honor
this order as if it were a Durable DNR order OEMS approval (Michael
Berg) If a patient is in a qualified health care facility such as a
nursing home or home on routine hospice care, a Durable DNR AND
POST form is not needed. The POST form is preferred due to its
comprehensive nature. 26
Slide 28
Section B Person Has Pulse and/or is breathing - Comfort
Measures -Limited Additional Interventions -Full Interventions All
care above plus intubation and cardioversion Note re: antibiotics:
Antibiotics are often life-sustaining treatments, so advance care
planning can help clarify goals of care in order to make the best
decision. It may be helpful to explain other treatments such as
antipyretics and opioids to treat symptoms of infection and
maintain comfort. 27
Slide 29
Section C: Artificial Nutrition Can be emotionally laden
discussions. Emphasize the medical nature of this decision. Explain
the medical, legal and ethical justification that artificially
administered nutrition is a medical intervention that can be
accepted or declined based upon the patients goals, values and
priorities. Surrogate decision makers can consent or decline the
intervention based upon their substitute judgment for the patient.
Address any and all fears of neglect and abandonment. 28
Slide 30
Signatures 29
Slide 31
Back Side of Form Signature of the health care professional
preparing the form. Directions for Health Care Professionals
30
Slide 32
Location And Transfer Of POST Form
Slide 33
Location Of The POST Form It is best if the original POST form
(canary yellow color) accompanies the patient when transferred or
discharged. A copy is acceptable, however, if the original document
is not available. The POST form is transferred in a large red
envelope, which stays with the original document (see next slide).
In Hospital or Nursing Facility: Will be kept in the very front of
patients chart. In Patients Private Residence: should be kept on
refrigerator door, either in red envelope or with easy access to
red envelope.
Slide 34
The Red Envelope for Transfer/Discharge
Slide 35
Envelope Label ORIGINAL POST/DDNR Form Enclosed Form is to
accompany Patient upon Discharge/Transfer PLEASE RETURN ORIGINAL
FORM IN THIS ENVELOPE TO: (Patient Name) (Address)
Slide 36
Transfer Of POST With Patient Red envelope with original POST
should be placed on top of transport papers. The healthcare
facility initiating the transfer shall communicate the existence of
the POST form to the receiving facility prior to the transfer. The
POST form shall accompany the person to the receiving facility and
shall remain in effect.
Slide 37
Modifying POST Decisions
Slide 38
To Review, Change, or Void POST Review of Form is required
when: 1. The patients preferences change 2. Patient is transferred
from one healthcare setting to another setting, including admission
to hospice care. 3. Patient has significant change in health.
Slide 39
To Review, Change, or Void POST Patient should always be
involved in review process, as well as his/her representative. An
ACP Facilitator and/or patient physician/NP/PA is preferred to lead
review process. When patient is new to our service, but already has
a POST form in place, the review should be coordinated.
Slide 40
To Review, Change, or Void POST There are 3 possible review
outcomes: NO CHANGE FORM VOIDED, new form completed Complete a new
form indicating the patients current wishes After doing so, write
the word VOID in large letters across the both the front and back
of the original POST form, and include the date the form was
voided. Keep the original in the patients medical record to be
archived according to agency policy. The new form will be kept with
the patient if living at home or in front of the facilitys chart
where her or she is located. FORM VOIDED, no new form
Slide 41
When Not To Complete A POST Form A POST form should not be
completed if the patient requests contradictory orders. One of the
most likely examples: the patient wants CPR in Section A, but wants
only limited additional interventions in Section B. The performance
of CPR requires full treatment. If the patient does not want full
treatment, including intubation and mechanical ventilation in an
ICU, then the patient should not receive CPR.
Slide 42
Slide 43
Take-Home Messages POST provides a better means than AD to
identify and respect patients wishes POST completion will improve
end-of-life care throughout the system Use of POST will require
communication to make it work in your community Know your role.
Wheres the POST form? 42
Slide 44
POST Resources Palliative Care Partnership of the Roanoke
Valley www.pcprv.org Contact Person for POST: Laura Pole,
[email protected][email protected] Virginia POST
Collaborative www.virginiapost.org Respecting Choices
www.respectingchoices.org See list of attached area professionals
who are certified as Trainers and/or Facilitators in Advance Care
Planning