CSI-RI Learning Collaborative October 9, 2014

David Gorelick, MD, FACPFull Time Practicing Internist Aquidneck Medical Associates in Newport

since 1995University Medicine Foundation member Jan

1, 2014Lifespan Corporation Board of DirectorsRI HIE (CurrentCare) Advisory Commission

Chairman

No financial disclosures in relation to today’s presentation

CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP

David Gorelick, MD, FACPAquidneck’s Physician Champion

EMR Super-User – fully electronic since 2005 EMR Training , Maintenance, and Upgrades Patient-Centered Medical Home – 1st in RI NCQA Level 3

in 2009 Practice Transformation – workflow efficiency and staffing

model All Quality and P4P Initiatives – 1st group in RI MU in 2010 CSI-RI beginning Oct, 2013

Newport Hospital Code Committee Chairman since 1995

Newport Hospital Case Management Advisor since 1999

CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP

Today’s DiscussionEnd of life care is an active

interventionWhose wishes are we honoring?

The patient’s? The family’s? The doctor’s?

Patient-CenterednessHaving the discussionLiving Will Durable Power of Attorney for

HealthcareWhere does code status fit in?Comfort OneMOLST

Transitions of Care

CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP

National Cancer InstituteEnd-of-Life Care for People Who Have Cancer

End-of-life care provides physical, mental, and emotional comfort, as well as social support, to people who are living with and dying of advanced illness.

People who have already discussed their wishes for end-of-life care with their loved ones feel less stress at the end of their life, and so do their families.

Advance directives are legal documents that record a person’s wishes for end-of-life care.

Research has shown that hospice care may improve the quality of life of a cancer patient who is dying and of the patient’s family.

CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP

Hospice CareNational Hospice and Palliative Care Organization

http://www.nhpco.org/Considered the model for quality compassionate

care for people facing a life-limiting illness.Hospice provides expert medical care, pain

management, and emotional and spiritual support expressly tailored to the patient’s needs and wishes.

Support is provided to the patient’s loved ones as well.

Hospice focuses on caring, not curing.

CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP

Case Report – 95y/o with anemiaInterventions vs conservative approach

Patient’s wishes were clearFamily’s agenda differed

CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP

Case Report – 80y/o not recoveringSeizure disorder and IDDM since childhoodAdvanced cardiac diseaseHip fracture, post-op course gone badPatient’s wishes were clear, family agreedIntensivist “interventions are necessary to

help her”. Whose wishes are being honored?

CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP

Case Report – 68y/o end stage cancer

Pain management issuesPatient/family consensus – pain control overnight, then home with Hospice

Admitting physician “we can fix this”One week hospitalization with supportive care interventions

Whose agenda is it?

CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP

Patient-CenteredRespect patients’ beliefs - ethical, religious

Honor the patient’s wishesHelp family through the processConsider Ethics Committee consultation if there are conflicts

CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP

Not Physician-CenteredObjective advice and supportWe don’t facilitate death, but we can actively comfort patients at the end of life

Don’t let technology and medical advances stand in the way of patients’ right to die.

CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP

Have the ConversationIn times of health as well as illnessAdvanced Directives – even the young

Durable Power of Attorney - sameResuscitation/Code Status - 65+, others with advanced illnesses

CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP

Have the Conversation AgainIn times of health as well as illnessWhen situations changeBuild it into the workflowEMR structured data sectionReportingPre-visit planning

CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP

Share the WishesPrimary Care PhysicianFamilyLocal hospitalStatewide Health Information Exchange

With each transition of care

CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP

Case Report – 92y/o acute abdomenPatient’s wishes were clearPCP provided support to emphasize patient’s wishes

Hospital service attending kept swaying the family towards intervention “we need to operate, would you rather do nothing and let her suffer?”

CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP

End of Life Care is an ACTIVE intervention

CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP

R.I. Living WillRights of the Terminally Ill Act Declaration

http://www.health.ri.gov/forms/legal/LivingWill.pdfA DeclarationI voluntarily make known my desire

that my dying shall not be artificially prolonged…

If I should have an incurable or irreversible condition that will cause my death…CSI-RI Learning Collaborative October 9, 2014 David

Gorelick, MD, FACP

R.I. Durable Power Of Attorney For Health Care

http://www.health.ri.gov/forms/legal/DurablePowerOfAttorneyForHealthCare.pdf

An Advanced Care DirectiveAppointment of Health Care Agent to make

health care decisions if you can no longer make decisions

Two qualified witnesses or one notary public must sign

CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP

R.I. Durable Power Of Attorney For Health Care

If I am close to death and life support would only prolong my dying

If I am unconscious and it is very unlikely that I will ever become conscious again

If I have a progressive illness that will be fatal and is in an advanced stageCSI-RI Learning Collaborative October 9, 2014 David

Gorelick, MD, FACP

Living Will/POA – Code Status?Distinguish between “life support” when

life brings you towards the end with a terminal condition vs Code Status

DNR should not have a menu of optionsComfort One

CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP

Comfort Onehttp://www.health.ri.gov/publications/

handbooks/ComfortOneEMSDoNotResusitateProgram.pdf

Bracelet applied to the patientEMS can provide care without “threat”

of resuscitationTerminal illness diagnosisAdvanced age, frail, failing to thrive?

CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP

CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP

Comfort One Bracelet

CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP

MOLSTMedical Orders for Life-Sustaining

Treatmenthttp://www.health.ri.gov/lifestages/

death/about/medicalordersforlifesustainingtreatment/

http://www.health.ri.gov/forms/medical/OrdersForLifeSustainingTreatment.pdf

Stand-alone, portable orders that follow the patient from facility to facility.

CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP

MOLST - elementsCPRMedical InterventionsTransfer to HospitalArtificial NutritionArtificial HydrationAdvance Directive

CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP

Transition of CareInterpreting patient’s wishes as they apply

to the current situation may be a challengeInvolve the familyInvolve the healthcare team

Inpatient MD’s, RN’sNCM’s – inpatient and outpatientPCP’sClergy

Leave egos at the door – focus on the patient

CSI-RI Learning Collaborative October 9, 2014 David Gorelick, MD, FACP

CSI-RI Learning Collaborative October 9, 2014