The NC MOST Form:What’s in it for LTC facilities,

patients families & providers?

NC Health Care Facilities Association WebinarAugust 2, 2012

With thanks to contributors…

Anthony J. Caprio, MDAssistant Professor of MedicineDivision of Geriatric MedicineCenter for Aging and Health

Palliative Care Consultation ServiceUniversity of North Carolina- Chapel Hill

John C. Ropp, III, MD, Chairman, SC CSI

“In my day, people died.”

The Problem

• Too many people are dying in places they would not choose, in ways they would not want, surrounded by strangers, their wishes undocumented, unknown and, therefore, often not honored.

• What we say we want is not what we get. In fact, what we get is often the exact opposite of what we would want.

Statistics

~80% wish to die at home

Over 85% say they want spiritual needs met

Over 90% want well-managed pain

~25% die at home

~6% have talked to their minister

~11% have talked to their MD

What has gone wrong?• The conversation is not taking place. Why?• Medicare (via PSDA) says “We’ll give you money if you have

the conversation.”• Reality is “We’ll take the money and hand out the

documents.”• Wrong place, wrong time, wrong person, wrong mechanisms.• Current EOL Care often does not reflect patients’ values and

preferences.• EOL Care costs a lot of money compared to other healthcare

expenditures.

Language & setting matter….• “Would you like information about advance

directives?” (Pt: “What does THAT mean?)• “I need a copy of your Living Will” (WHY?)

OR• “We want to provide you with the best care possible.

These documents will help us understand and honor your wishes.”

• “Have you talked with your family & physician about the kind of care you want? This information may help.”

Conveyor Belt??

• You may have a good relationship with your PCP, however…..

• Count the number of specialists and treatment settings the patient encounters…..

• Stepping into a modern day emergency center is like stepping onto a moving train.

David Blackmon, MDiv, Asheville, NC

Treatment settings• Outpatient settings• Emergency rooms• ICU• Step-down units – hospitalists• Med/Surg units• Rehab• Palliative care• LTC• Hospice

What happens in the ED?

• Why is this patient here?• What does this patient want?• How aggressive should we be?• Do I intubate this patient?• Who is involved in this patient’s care?• What is the appropriate disposition?

Limitations of Advance Directives

May not be available when needed

May not be specific enough

Does not translate immediately into medical order

Literature Review on Advance Directives, June 2007 http://aspe.hhs.gov/daltcp/reports/2007/advdirlr.htm

It’s not about the documents!

It’s about the conversation.

It’s about the patient’s right to choose.

How do we communicate our wishes?

•

Technology of Critical Care

www.icu-usa.com/tour

•

Treatment Options• CPR• Artificial hydration• Artificial nutrition• Artificial ventilation• Antibiotics• Dialysis• Chemo/radiation therapy• Pharmaceuticals• Pace makers

Should ‘everything’ be done?

Knowledge Wisdom

When is Enough Enough?The Ethics of Over-treating or

Under-Treating Patients at the End of Life: Do good; Do no harm; Prevent harm

Right vs. RiskIs it time for us to look at what we are

doing and why we are doing it?

What does all this have to do with the National POLST Paradigm

and the NC MOST form?

EVERY THING!

Basis of POLST

Encourages discussion about key end of life care issues

Patients

Families or surrogate decision-makers

Health care providers

POLST Paradigm Purpose

The Physician Orders for Life-Sustaining Treatment (POLST) Paradigm program is designed to improve the quality of care people receive at the end of life.

It is based on effective communication of patient wishes, documentation of medical orders on a brightly colored form and a promise by health care professionals to honor these wishes. It is a win-win for all involved.

National POLST Paradigm

A win-win for

everyone

POLST History

• 1991 - Patient Self Determination Act• 1991 - POLST form developed in Oregon• 2002 - POST in West Virginia• 2007 - MOST in North Carolina

POLST Paradigm 1990

Developing Programs*As of January

2011

Endorsed Programs

No Program (Contacts) Designation of POLST Paradigm Program status based on information available by the program to the Task Force.

National POLST Paradigm Programs*

Developing Programs

National POLST Paradigm Programs

Endorsed Programs

No Program (Contacts)*As of February 2012

What fueled the spread of the POLST

Paradigm?

Do Not Resuscitate (DNR) Order

• Medical Order

• Issued by a physician (NP or PA)

• Not hypothetical; immediately “in effect”

• No interpretation, immediately directs care in the event of a cardiac arrest

Beyond Resuscitation• Except in the event of cardiopulmonary arrest,

resuscitation orders do not direct other treatments– Some patients desire an attempt of resuscitation but want to

limit other types of treatment– DNR does not necessarily imply other treatment limitations

(DNR ≠ Do Not Treat)

• What other kinds of treatments might the patient receive (or not receive) if they had a DNR order?

Tanabe M. Annals of Long Term Care 2004;12:42-45Zweig SC, et al. J Am Geriatr Soc. Jan 2004;52(1):51-58.Hickman SE, et al. J Am Geriatr Soc 52:1424–1429, 2004.

Medial Orders for Scope of Treatment (MOST) form

• More than a DNR order

• Guide care even when patient has not arrested

• Options to receive or withhold treatments

• Avoid inappropriately limiting or providing other types of treatments

Pink MOST Form

• Identifiable: consistent pink color

• Flexible: allows accepting or refusing treatments

• Actionable: medical orders

• Up-to-date: reviewed regularly

• Portable: transfer across health care settings

MOST: 5 Sections

A. Cardiopulmonary Resuscitation (CPR)

B. Medical Interventions

C. Antibiotics

D. Medically Administered Fluids & Nutrition

E. Discussed with and agreed to by…

Section A: CARDIOPULMONARY RESUSCITATION

Attempt Resuscitation (CPR)

Do Not Attempt Resuscitation(DNR/no CPR)

• Only one option should be selected.

• Only applies if there is no pulse and the patient has stopped breathing(cardiopulmonary arrest)

Survival After Cardiopulmonary Resuscitation (CPR)

• Generally, only 10-15% survive to hospital discharge; many with impairments

• Lower rates of survival (<5%)– Unwitnessed arrest– Certain types of heart rhythms– Multiple chronic diseases

• Survival for nursing home patients 0-3%

Inaccurate Perceptions of Survival

• General belief of 65% survival after CPR

• 67% of resuscitations successful on TV

• Probability of survival influences choices– Nearly one-half of older

adults changed their mind about wanting CPR after hearing about the true probability of survival

NEJM 1996: 334:1578-1582NEJM 1994; 330:545-549

Goals of Medical Care• Prioritized goals provide context for medical

decision making 1) Longevity2) Function (maintain/restore)3) Comfort

• Rarely, can all three goals be maximized simultaneously

• As clinical circumstances change, goals are reprioritized

J Am Geriatr Soc 1999;47(2):227-230

Section B: MEDICAL INTERVENTIONS

Full Scope of Treatment

Limited Additional Interventions

Comfort Measures

• Guidance about the intensity of care and the patient’s goals

• Patient is not experiencing cardiopulmonary arrest(No indication for CPR)

Prioritize Goals of Care1) Longevity

2) Function (maintain/restore)

3) Comfort

J Am Geriatr Soc 1999;47(2):227-230

Full Scope of Treatment

• Intubation/mechanical ventilation• Cardioversion• ICU admission• Transport to the hospital if indicated• All other appropriate treatments

• Patients electing “Full Scope” usually express longevity as the primary goal of care

Limited Additional Interventions• No intubation/mechanical ventilation• No cardioversion• Would likely not be admitted to the ICU• Transport to the hospital if indicated• “Other instructions” can be used for clarifications

• Goals of Care– Usually do not prioritize longevity as their major goal– May express other goals like maintaining or restoring

function– May opt for therapeutic trials and withdraw therapies if

they are ineffective or become burdensome

Comfort Measures• These patients prioritize comfort as their most

important goal of care

• Care is focused exclusively on relieving distressing symptoms

• No intubation/mechanical ventilation• No cardioversion• No ICU admissions• Transport to the hospital ONLY if comfort needs can

not be met in the current location

POLST USERS WITH COMFORT MEASURES ONLY

•67% less likely to receive life sustaining medical interventions compared to POLST full treatment.•Research shows that most people select “limited additional interventions.”

SECTION B

P<0.004

Section C: ANTIOBIOTICS

To receive antibiotics if life can be prolonged

To determine use or limitation of antibiotics when infection occurs

No antibiotics, in which case other measures would be used to relieve symptoms

Section D: MEDICALLY ADMINSTEREDFLUIDS AND NUTRITION

• IV fluids options: To receive if indicated To receive for a defined trial

period No IV fluids

• Feeding tube options: To receive if indicated To receive for a defined trial

period No feeding tube

Nutrition and HydrationBenefits and Burdens

• Often religious and cultural beliefs guide a patient’s decision

• Discussed in the context of goals of medical care

• IV fluids may not promote comfort at the end of life– Swelling– Shortness of breath– Need for frequent urination.– Excessive secretions

• Feeding Tube decisions are complex– Promotes longevity in some cases (ie. brain injury)– No clear survival benefit in advanced dementia

• Comfort care measures: ice chips and mouth care

Trial Periods or Time-Limited Trials

• Not starting and stopping are equivalent

• Emotionally, stopping is often more difficult

• When goal is not achieved, shift focus

• Sometimes difficult to define duration

Section E:DISCUSSED WITH AND AGREED TO BY:

1. Patient

2. Parent or guardian if patient is a minor

3. Health care agent

4. Legal guardian

5. Attorney-in-fact with power to make health care decisions

6. Spouse

7. Majority of patient’s reasonably available parents and adult children

8. Majority of patient’s reasonably available adult siblings

9. An individual with an established relationship with the patient who is acting in good faith and can reliably convey the wishes of the patient

Revocation of MOST• MOST no longer reflects

patient’s preferences

• Put line through the front page and write “void”

• “Form VOIDED” in the Review section on back of MOST– New form completed– No new form

Void

MOST is . . .• Optional

– Won’t work for everyone– Another instrument to help

honor patient wishes

• Identifiable– Bright pink color

• Flexible– Accept or reject medical

treatments– More than resuscitation

preferences

• Portable– Travels with the patient– Directs care in a variety of

settings

• Medical Order– Immediately directs care

• Reviewed Regularly– Annually– Changes in health status– Admissions/discharges

MOST is NOT…• A replacement for an advance directive

• Intended for those with a low risk of dying– Rather than progressive decline from chronic disease, healthy patients

are at risk for sudden catastrophic events associated with prognostic uncertainty

– Likely to benefit more from a Health Care Power of Attorney

• Available for patients to download or from their attorney– Must be signed as a medical order by a physician, PA, or NP– Should be completed after a discussion of goals of care, prognosis, and

benefits/burdens of treatments.

WHO SHOULD HAVE A MOST

FORM?

People with….• Terminal illness• Advanced disease• Prognosis of death within a year• Debilitating chronic progressive

illness• A strong desire to document their

treatment options in the form of a physician order

Executive Committee

Statewide Steering Committee

Regional Coalitions (7) Task Forces

Education for LTC/ Assisted

LivingConsumer Education

Acute Care Education

Quality/Research/

Data Registry

North Carolina Compassionate Care Partnership (Working Name)

EMS Education Education for

Professionals

Sustainability/Funding

The NC Compassionate Care Partnership

• Two year pilot project in Asheville• Endorsed as a developing state in 2007• State is divided into seven regions• Topic task forces include education for EMS;

LTC/ALFs; healthcare professionals; consumers; acute care settings; quality, research & data; sustainability & funding and MOST registry

Educational Initiatives to date

• 2000 – present: RWJ Community EOL Care Coalitions and Respecting Choices ACP Facilitator Training

• NCMS – www.ncmedsoc.org• OEMS - www.ncems.org• AHEC – conference in Asheville, Charlotte,

Greenville, Raleigh and Wilmington• Respecting Choices MOST Advance Care Planning

Facilitator Certification Course• Regional and local initiatives

Goal is to Improve Care

Measure outcomes Determine patterns of care Transition patients from one level of care

to another in a timely, appropriate manner Provide feedback Revise system as needed

Benefits of POLST/MOST• Facilitates appropriate EMS tx• Facilitates HIPAA compliant transfer of

records between healthcare settings• Centralizes info; facilitates record keeping• Enhances link among LTC, EMS, ED, ICU,

Palliative Care Services, Hospice

GIVEN AN OPPORTUNITY ONLY 12% OF LONG TERM

SKILLED NURSING FACILITY

RESIDENTS WANT ICU CARE

CAPC & POLST Summary & Conclusions1. Palliative medicine leaders play key roles in

health system implementations of POLST Paradigm

2. POLST is associated with reduced unwanted hospitalizations

3. Electronic registry's can improve access

Take Home Messages

• MOST form provides means to identify and respect patients’ wishes

• MOST form completion will improve end of life care throughout the system

• Use of MOST form will require communication to make it work in your community

• Documentation and transportation mechanisms• MOST protects patients, providers and systems

Resources

www.polst.orgwww.respectingchoices.orgwww.ncmedsoc.orgwww.cchospice.orgwww.caringinfo.orgwww.kidneyeol.orgwww.compassionandsupport.orgwww.coalitionccc.org www.wvaendoflife.org

Contact Information

Dee Leahman, DirectorCommunity Partnership for End of Life CareHospice & Palliative CareCenter101 Hospice LaneWinston-Salem, NC 27103336-331-1317Dee.Leahman@hospicecarecenter.org