Making Tough Conversations Making Tough Conversations Less Difficult:Less Difficult:

Helping Patients & Families with Helping Patients & Families with Advanced Care PlanningAdvanced Care Planning

Adele W. Pike RN, EdDVisiting Nurse Association of Boston and Affiliates

Christine McCluskey RN, MPHCommonwealth Medicine, UMASS Medical School

Jane Pike-Benton RN, MSHomeHealth & Care Transitions MetroWest HomeCare &

Hospice

Wednesdays At the Wednesdays At the MoviesMovies

An educational series to help home care clinicians engage patients and families in discussions about their goals of care, care

options, and advanced care planning

“I never want to go back into the hospital again.”

Video Clips Video Clips The Shootist Terms of Endearment Little Miss Sunshine Wit Tuesdays with Morrie Steel Magnolias Young At Heart Bill Moyer’s How We Die PBS Caring for Parents PBS Living Old

Mother and Daughter in Mother and Daughter in ProvidenceProvidence

(video clip)(video clip)

WGBH Educational Foundation (2008). Caring for Your WGBH Educational Foundation (2008). Caring for Your ParentsParents

What we found:What we found:Muriel Gillick’s framework for talking

with patients about goals of care really worked for our clinicians

Advanced Care planning is an ongoing discussion, not a one time event

How much each of us imposed our own goals on a patient’s situation instead of listening for the patient’s goals

Our clinicians were not aware of all the resources Hospice offered, including consultation around symptom management and joint visits

There is a need for more community based palliative care resources

Muriel Gillick’s FrameworkMuriel Gillick’s Framework

LongevityComfortFunction

Gillick, M.R. (2001). Choosing Appropriate Medical Care for the Elderly.

Journal of the American Medical Directors Association. 2(6), 305-309.

Changes in Practice Among Changes in Practice Among our Clinicians:our Clinicians:

For more information about

Wednesdays at the Movies...

Contact :

APike@VNAB.org

A process for discussing, documenting, communicating & honoring patient preferences for life-sustaining treatments

A standardized form for writing & communicating medical orders for life-sustaining treatments

A portable document that travels with the patient & is honored by health care professionals across care settings

Voluntary for patients of any age who are nearing the end of life

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Key facts about MOLST in Key facts about MOLST in MAMA

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Part of advance care planning, but not an advance directive, and it takes effect immediately on completing form

Is an implementation tool for advance care planning conversations applied to current medical decision making

Represents the standard of care for documentation of patient and clinician discussions with the resulting medical orders

Can be used to refuse or accept life sustaining treatments

MOLST Form MOLST Form

Page 1:◦ Medical Orders for

Life Sustaining Treatments

◦ DNR, DNI, DNH

Page 2:◦ Statement of Patient

Preferences for Other Medically Indicated Treatments

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MOLST Goal: MOLST Goal: to improve patient-to improve patient-centered care bycentered care by

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MOLST and the Health Care MOLST and the Health Care Proxy Proxy

• MOLST does not replace the need for all adults (age 18 & older) to complete a Health Care Proxy form to appoint a health care agent.

• A health care agent is the person authorized to make health care decisions on one’s behalf in the future if one loses capacity to make health care decisions.

• A MOLST form contains medical orders based on a patient’s own preferences. It is suitable for very sick patients nearing the end of life & goes into effect as soon as it is signed.

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Transitions of Care & Transitions of Care & MOLSTMOLST

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MOLST Statewide MOLST Statewide Expansion Principles Expansion Principles

1. Strategic Collaboration Collaborate with statewide, cross-continuum initiatives already underway in MA Don’t “re-invent the wheel”

2. Capacity Expand MOLST first in organizations that have both interest in MOLST & capacity to implement MOLST Expand MOLST to other health care organizations & institutions in the Worcester area

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For more information go toFor more information go towww.MOLST-MA.org

Provide the right care for each patient at the right time in the right care setting

Multi-disciplinary approach to shift the culture of our acute care facilities

regarding serious illness and end of life care

Palliative Care Program - MissionPalliative Care Program - Mission

Fall 2009 STAAR Team record review of readmitted

HF patients reveals multiple patients with chronic HF and end of life concerns.

Our JourneyOur Journey

May 2010 MetroWest Medical Center Ethics

Committee ask MetroWest HomeCare & Hospice to collaborate to develop an Inpatient Palliative Care Program August 2010

Saint Vincent Hospital and MetroWest HomeCare & Hospice team up to create a cross-continuum Inpatient Palliative Care Program

Feb 2011 Inpatient Palliative Care Program begins

consults at MWMC

Our JourneyOur Journey

April 2011o Inpatient Palliative Care Program begins

consults at SVH

Palliative Care Steering Committee approves policies & procedures, physician

order sets and drives the cultural shift through education

Palliative Care Consult Team meets with patients, family members and

health care team members to discuss patient wishes and options

Palliative Care Program StructurePalliative Care Program Structure

Important to align the Palliative Care Program with the Ethics Committee, Cancer Care Center, Intensive Care, Emergency Department, Physicians, Hospitalists, Nursing and Chaplaincy, as well as other care team members

Palliative Care Program StructurePalliative Care Program Structure

Additional ResponsibilitiesAdditional Responsibilities

o Policies and Procedureso Physician Order Seto Education at Physician, Nursing and

Administrative Meetingso Schwartz Roundso Palliative Care Informational Fairs

RESOURCESRESOURCESIntroduced in 1997 with funding from a grant from the Robert Wood Johnson Foundation

Changes the way we talk about and plan for care at the end of life

Simple to use

Available in 15 languages

Can also be completed on line

Enhance pain and symptom management Care concordant with patient-family

preferences Improved patient and family satisfaction Reduced costs via shorter length of stay,

decreased readmissions and less acute treatment ordering

Earlier transition of care to Bridge or Hospice care

Hospital – Hospice Partnerships in Palliative Care Benefits as per NHPCO

Patients who are discharged savings- $1696

Patients who die in the hospital savings - $4900

Decreased readmission rate of patients with chronic and/or end of life illnessMorrison et al published an article in The Archives of Internal

Medicine 2008;168(16):1783-1790. “Cost Savings Associated with US Hospital Palliative Care Consultation Programs”

Other Potential Benefits

Palliative Care Outcomes

169 consults completed in the first 7 months

169 consults completed in the first 7 months

Many patients with chronic illness unrelated to cancer

37% of patients were admitted from Skilled Nursing Facilities

It’s about how you liveIt’s about how you live

ResourcesResources

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Discussion & Reflection