Fine Tuning the POST System: T he Case of an Invalid, Contradictory POST Form

1. Fine Tuning the POST System:The Case of an Invalid, Contradictory POST Form Alvin H. Moss, MD, FACP, FAAHPM Center for Health Ethics and Law

2. Objectives • Analyze a case which highlights the importance of POST form completion • Describe the most recent evidence on the impact of advance directives in the country • Identify the advantages of the POST system over advance directives to honor patients’ end-of-life care wishes • Explain how the WV e-Directive Registry will enable patients’ end-of-life care wishes to be respected • Discuss common errors on forms submitted to the Registry At the conclusion of this conference, participants should be able to:

3. Fine Tuning the POST System: The Case of an Invalid, Contradictory POST Form A 78 year-old woman was admitted from a nursing home with chest pain. She had a past history of coronary artery disease status post stent placement, congestive heart failure, hypertension, lipid disorder, and mild dementia. A POST form accompanied the patient and indicated CPR in Section A and Limited Additional Interventions in Section B. The EMTs and later the attending physician wondered what he should do with the POST form because Section A and Section B seemed to be contradictory. The POST form had been prepared by a social worker who had signed it, but there was no physician signature on it. In transporting the patient, EMS worried, “What do I do if she codes and I do CPR and get her back, but she is not breathing normally? Do I intubate her?” The emergency department physician wondered the same thing, but fortunately she did not suffer a cardiac arrest during transport The attending physician saw the patient in the emergency department and reviewed the POST form without any additional notes or documentation.

4. Fine Tuning the POST System: The Case of an Invalid, Contradictory POST Form cont’d When interviewed by the palliative care team who was consulted to address the POST form inconsistency, the patient indicated that she would not want to be kept alive on machines and when it was explained to her that if she had CPR and lived through it, it was very likely that she would end up being on a breathing machine. She said, “Well then, I don’t want CPR.” A revised POST form was created and signed by the patient and the palliative care physician. The patient was discharged back to the nursing home. The daughter who lived out of state and who was the patient’s Medical Power of Attorney representative reviewed the POST form and stated she wanted her mother to have CPR. What should be done with regard to the contradictory POST form and the daughter’s request? How could these situations be prevented in the future?

5. Learning Issues • Who should be making the decisions for this patient and on what basis? • How should that person legally be designated? • How should the POST form be completed and what should be indicated in each section? • What should be done with the POST form after it is completed? • How could the conflict in this case have been prevented?

6. Latest Studies The Outcomes of Advance Care Planning (ACP) The vast majority (⅔ to over ¾) of older adults are willing to participate in ACP ACP results in statistically significantly different and improved EOLC for patients Silveira MJ et al. Advance directives and outcomes of surrogate decision making before death. N Engl J Med 2010;362:1211-1218. Detering KM et al. The impact of advance care planning on end-of-life care in elderly patients: randomised controlled trial. BMJ 2010;340:c1345. doi:10.1136/bmj.c1345

7. Outcomes of Advance Directives • Of 3746 older adults (>60 yo), 42.5% required EOL decision making • Of these 1,536 older patients who required EOLC decisions, 70.3% lacked capacity • In short, 29.8% of older adults required EOL decisions but lacked capacity • Of these 999 patients, 67.5% had advance directives • Patients with an advance directive were significantly more likely to want limited or comfort care and receive it Silveira MJ et al. Advance directives and outcomes of surrogate decision making before death. N Engl J Med 2010;362:1211-1218.

8. Elements of the Advance Care Planning Process • Begins by clarifying the patient’s current health status • Moves to elicitation of the patient’s goals of care • Identifies the patient’s preferred decision-maker if the patient loses decision-making capacity • Completes a Physician Orders for Scope of Treatment (POST) form to ensure patient’s wishes are respected Gillick MR. Reversing the code status of advance directives? N Engl J Med 2010;362:1239-1240.

13. Hickman, SE, et al. A Comparison of Methods to Communicate Treatment Preferences in Nursing Facilities: Traditional Practices Versus the Physician Orders for Life-Sustaining Treatment Program. JAGS. 2010; 58: 1241-1248.

15. Hickman, SE et al. The Consistency Between Treatments Provided to Nursing Facility Residents and Orders on the Physician Orders for Life-Sustaining Treatment Form. JAGS. Published online: 22 Oct 2011

16. Elements essential to reliable, high-quality care for patients with fatal chronic illness—a systems approach Lynn, J. et. al. Ann Intern Med 2003;138:812-818

17. Communication across Settings “…the health care 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.” Code of West Virginia, §16-30-1 et seq.

18. Components of the System • Standardized practices and policies • Trained advance care planning facilitators • Timely discussions prompted by prognosis • Clear, specific language on an actionable form • Bright form easily found among paperwork • Orders honored throughout the system • QI activities for continual refinement • Statewide registry so that forms are available

19. Legal Protection with POST Use • Standardized form according to state law • Legally recognized DNR identification • Protection from civil or criminal liability for good faith compliance with and reliance upon POST • Protocol for use in interinstitutional transfers • Law covers compliance with POST when completed by MD not credentialed in facility

20. Transfer of POST Form • Copier to the Photo/Picture setting • Contrast to the lowest setting • Double-sided copies on 8 ½ x 11” Astrobrights Pulsar Pink 24 lb. paper* • Adjust the contrast setting on your copier to achieve the clearest possible copy • Can copy white FAX onto pink paper *Office Depot, Office Max, Staples

21. Form Shall Always Accompany Patient/Resident When Transferred or Discharged! On the top of the transfer packet!

22. The “surprise” Question: A Trigger for Palliative Care Evaluation and Advance Care Planning “Would I be surprised if this patient died in the next year?” Moss et al. Utility of the “surprise” question to identify dialysis patients with high mortality. Clin J Am SocNephrol 2008;3:1379-1384. Moss et al. Prognostic significance of the “surprise” question in cancer patients. J Palliat Med 2010;13:837-840

23. Accurate, relevant information available in a medical crisis • 24/7 online access by health care providers through WVHIN • Consumer able to confirm online accuracy of their advance directives and medical orders (DNR and POST forms) in the Registry • Patients’ wishes will be respected throughout the continuum of health care settings • Password-protected – HIPAA compliant Registry FAX 304-293-7442

24. Problems with POST Completion • Just 4 errors make up 72% of all the “not Registry ready” POST forms.

25. The Most Common POST Form Errors • The Opt-In Box was not initialed • The form is missing pages • Conflicting elections in sections A and B • Physician’s signature is missing

26. Take-home Messages • Be sure to initiate advance care planning discussions with patients for whom you would not be surprised if they died in the next year • Complete POST forms as part of advance care planning • Submit forms to e-Directive Registry so that patient’s medical orders will be available in a crisis

27. Contact the Center for… • ● DNR Cards ● POST Forms ●Brochures • Advance Directives ● Health Care Surrogate Forms www.wvendoflife.org 877.209.8086 FAX 304.293.7442