Actionable Advance Directives

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Actionable Advance Directives

• Stephen Telatnik,M.D.
• Hope for the Future
• Achieving the Original Intent of
• Advance Directives

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GOALS

• Review the reasons why advance directives have
  not achieved the status expected in the last 20
  years.
• Explore possible improvements and examples.
• Concentrate on actionable medical directives
  especially POLST.
• Review progress in El Paso County and Colorado
  towards actionable medical directives.

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What are actionable medical directives?

• Physician medical orders regarding end of life
  issues
• Do not replace traditional medical directives.
• Help to define in a timely manner patients wishes
  in specific areas.
• Need to transfer across care settings.

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Statutory Advance Directives

• Only 20 to 30 percent of American adults have
  advance directives.
• Limited effect on end of life treatment

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Reasons for Failure

• Focus on legal rights to refuse treatment without
  understanding the persons goals and values.
• Instructions are either too vague or too specific
  to lead to constructive conversations and
  decision making.
• No timely follow-up after initial form completed
• Not integrated into clinical care planning

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Reasons for Failure (cont.)

• Autonomy is assumed to be the primary mode of
  decision making.
• Insufficient instructions are included for
  surrogates and/or physician.
• Intention of patient to allow surrogate to make
  decisions is not addressed.

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Elements of Successful AD Programs

• Individualized plan must include persons values,
  goals, medical condition,and culture.
• Actionable AD involves physician orders for
  current treatment preferences across care
  settings utilizing a standardized highly visible
  form. .
• Staged timing revisit AD with changing prognosis
• Increasing chronic disease and frailty
  necessitate review of goals frequently.

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Elements (cont.)

• Policies, procedures and teamwork within each
  part of the healthcare system are necessary.
• QA initiatives to ensure each element of the
  system is achieving desired outcome.
• States end of life coalitions of key stakeholders
  is essential to ensure portability.

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New Models

• Five Wishes
• Let Me Decide
• Respecting Choices
• POLST

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FIVE WISHES

• Incorporates surrogate appointment with range of
  wishes medical, personal, spiritual and
  emotional needs.
• Meets legal requirements in 37 states including
  Colorado and District of Columbia.
• No published studies to support efficacy.

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LET ME DECIDE

• Program in Ontario, Canada nursing homes and
  hospitals to document health care choices in
  several areas.
• Staff training on how to integrate AD into care.
• Documented increase level of planning and
  decreased deaths in hospitals.

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RESPECTING CHOICES

• Community-wide care planning system in La Crosse,
  WI
• Training and defined role for HCP in advance
  planning
• 85 of all decedents had written AD
• Medical decisions near time of death were
  consistent with written instructions 98 of
  the time.

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Physician Orders for Life Sustaining Treatment

• Order form that converts patient treatment
  preferences into written medical orders primarily
  in nursing homes
• Form transfers with patient across care settings
• Used in thirteen states
• Respecting Choices recommends POLST

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POLST

• Brightly colored, clearly identifiable form
• Orders that address a range of life-sustaining
  interventions.
• Portability across treatment settings requires
  acceptance and understanding of EMS, ER, and
  hospital personnel.

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Case Study

• 73 y/o male with total knee replacement admitted
  to nursing facility for rehab.
• On admission, physician reviews with patient and
  signs POLST.
• Wishes to be resuscitated, receive full
  treatment, antibiotics and tube feeding.
• He develops PE, transferred to the hospital and
  receives full treatment.

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FAQS

• Who should have the original form?
• Should be with patient at all times
• Does the POLST require pt. signature?
• It is not an AD, which does require it.
• What if patient has an AD?
• AD will provide information to complete POLST
  form

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FAQS

• Can the POLST be used to guide daily care?
• Yes, it provides information regarding transfer
  to hospital and about feeding tube insertion.
• Does a physician need to fill out form?
• No, can be done by nurse or social worker.
• Can the form be filled out without a conversation
  with the patient or surrogate?
• No, it must also document who was asked.

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History of POLST

• A state wide effort in Oregon coordinated by
  OHSU Department of Ethics
• Task force organized in 1991 and POLST form
  finalized in 1995.
• Project was in place three years before the Death
  with Dignity Act passed.
• Ongoing research contributes to improvements in
  POLST.

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POLST research

• Numerous studies published in peer-reviewed
  journals documenting efficacy
• Hickman et al JAGS 321424-1429 2004
• 2002 71 of Oregon nursing homes using POLST
  for at least 50 of patients
• Records audited at 7 facilities 88 completed
• DNR pts 54 chose other limitations
• Non DNR pts 47 chose some limitation

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The National POLST Paradigm Initiative

• Promotes the concepts of POLST across the country
• Supports coalition building and statewide
  collaboration.
• Provides educational material for healthcare
  professionals and lay public.
• Supports ongoing research about POLST and end
  of life issues.

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The National POLST Paradigm Initiative

• Programs based on the POLST paradigm are now used
  in Washington and West Virginia and parts of
  Wisconsin, Pennslyvania, New York, Utah, New
  Mexico, Michigan, Georgia, and Minnesota.
• Currently, there is a dialog with NPPI here in
  Colorado however, we have not met guidelines to
  be formally included.

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Actionable Advance Directives in Colorado

• Colorado Advance Directives Consortium organized
  August 18, 2006. The steering committee
• Denver Regional Council of Governments
• Task force on EOL, State Bar Association
• Colorado Dept. of Health, EMS Division
• Colorado Medical Director Assn. (LTC)
• Colorado Med. Society/El Paso County Med. Society
• Hospice Physicians

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Colorado Advance Directives Consortium

• Convened a meeting of interested parties on
  September 29, 2006 in Denver
• Topics discussed
• Living will law and legislation
• Portability of advance directives
• Proxy and surrogate decision-maker
• CPR Directive issues

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Colorado Advance Directives Consortium

• Since the general meeting in August 2006, the
  steering committee has investigated the issue of
  portability extensively.
• After a teleconference with a Dr. Dunn of the
  National POLST Paradigm Initiative, the
  Consortium has decided to explore the possibility
  of using POLST in Colorado

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Colorado Advance Directives Consortium

• The Consortium is supporting pilot projects in EL
  Paso County as well as Denver.
• The Centura system as well as Evercare has
  already began projects.

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El Paso County

• El Paso County Medical Society
• Ethics Committee/Probate Section Bar Assn
• Regularly monitors and promotes POLST activity
• Extended Care Ethics Committee
• Oversees POLST activities in nursing homes
• Meeting is being planned with EMS, ER, and
  hospitals
• Penrose Hospital is introducing POLST for
  inpatients is discussions with Memorial Health
  Systems.

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Southern Colorado

• Under the direction of Dr. Feinsod, nursing
  homes, EMS, and local hospitals in three
  communities have initiated POLST discussions.

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In Conclusion

• Reviewing the history of advance directives has
  led to innovative ways of protecting the wishes
  of individuals approaching the end of life.
• Physician orders for life-sustaining treatment
  across all care settings appears to be the most
  reasonable way to achieve this goal.