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Failure in Advance Care Planning

Failure in Advance Care Planning. 2008 report to Congress: efforts to promote better end of life care with advance directives have largely failed Two exceptions: Respecting Choices POLST. The Nature of this Failure. Advance Directives rarely available to clinicians

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Failure in Advance Care Planning

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  1. Failure in Advance Care Planning • 2008 report to Congress: efforts to promote better end of life care with advance directives have largely failed • Two exceptions: • Respecting Choices • POLST

  2. The Nature of this Failure • Advance Directives rarely available to clinicians • Even where Advance directives effectively promoted and available, not associated with better care at the end of life

  3. Exception: 1996 La Crosse Advance Directive Study • 85% of decedents had ADs at the time of death • 95% of the time the ADs were in the medical records of the institution giving the care at the time of death • 98% of the time the care given was consistent with the ADs

  4. 2011 NHHA 1 Day Inpatient Survey

  5. Lacrosse: 6 goals are part of routine care • Adult patients invited to reflect on and discuss plans for future health care relevant to their stage of illness • Adult patients are provided competent assistance by trained non-physicians in the planning process at all common sites of care • Plans are accurate, as specific as possible and understandable to all stakeholders

  6. Lacrosse: 6 goals are part of routine care • Written plans are stored, transferred, and retrievable wherever a patient is being treated • Plans are updated and become more specific as illnesses progress • POLST initiated for patients whose death would not be a surprise within 1 year • Plans are reviewed and honored at the right time

  7. Exception: Physician Orders for Life-sustaining treatment • Initiated in Oregon in 1993 • La Crosse the first location outside Oregon to use POLST in 1997 • POLST converts preferences of a patient whose death within a year would not be unexpected • into specific, relevant medical orders • on an order sheet that is honored in all care settings

  8. La Crosse Refinements • User-friendly state statute compliant document replaced WI statutory document • Easier to read and understand • Tips about how to make specific decisions • How to pick an effective health care agent • County-wide EMR launches all ACP documents from a single summary page • Includes POLST, ADs, MD commentary • Access from any record 5-10 seconds

  9. OUTCOMES • “Best Place to die in America” • Less unwanted care: • Serves 2/3rds of the triple Aim • Enhance healthcare value • Hospital days in last year of life in La Crosse 13, compared to 26 nationally “We spent so much time pulling bodies out of the river we decided to go upstream and see who was throwing them in up there…”

  10. Stages of Advance Care Planning Over the Life Time of Adults Next Steps ACP: Determine what goals of treatment should be followed if complications result in “bad” outcomes. Last Steps ACP: Establish a specific plan of care expressed in medical orders using the POLST paradigm. First Steps ACP: Create POAHC and consider when a serious neurological injury would change goals of treatment. Adults with progressive,life-limiting illness, suffering frequent complications Adults whom it would not be a surprise if they died in the next 12 months. Healthy adults between ages 55 and 65.

  11. “Next Steps” in NH • Coalition for Health Care Decisions • Training plans to extend “Respecting Choices” October 2011 • POLST in draft • Pilot programs beginning • Opportunities and barriers

  12. NH Coalition for Health Care Decisions • Training • Extends previous “Respecting Choices” • On-line and face-to-face segments • Applications for grants • POLST form consistent with statutes • Draft available for comments • Email PLClary@aol.com for electronic copy or to make comments

  13. Seacoast Pilot • Variation of West Virginia POLST Form in use since 2005 • Large public nursing home and community hospital partners • Process: Family meeting within 3 months of admission to nursing home • Goals of care • Prognosis • Projected benefits of hospice • Documentation of POLST form if desired

  14. Pilot results • Reduced hospital admissions past six months • Pilot facility: 0.37 hospitalizations/1,000 bed days • Control facility: 0.84 hospitalizations/1,000 bed days • Similar-sized facilities - control had 66 hospitalizations, pilot had 29 • Pilot facility IMPROVED family survey scores for physician services significantly before and during study period (2005; 2010) • 20% Higher hospice referrals in pilot facility

  15. Opportunities and barriers • Well-established state organizations helping jump-start process • Coalition for health care decisions • NHHPCO • Core of Clinician Champions is Key • Has already been presented to palliative care clinicians networking group • Plan for incremental change: 10 year process • Principal Barrier: training and education especially for physicians/APRNs/facilitators

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