Increasing Appropriate Hospice and Palliative Services throughImproved Communication and Documentation of Patients’ Wishes

Elizabeth Balsam Hart, MDMaineGeneral Health

With support from the Practice Change Fellows Program, the Atlantic Philanthropies and the John A Hartford Foundation

“How people die remains in the memories of those who live on.”

Dame Cicely Saunders

3

Divisions by Health Status in the Population andTrajectories of Eventually Fatal Chronic Illnesses

Joanne Lynn, MD, MA, MS, Center to Improve Care of the Dying, RAND

Divisions in the Population

Group 1

Group 2

Group 3

“Healthy,” needsacute and

preventive care

“Chronic, not “serious”

Chronic, progressive,eventually fatalillness

Major Trajectories near Death

AA

TimeLow

High

Func

tion

Func

tion

death

Time

BB

Low

High

Func

tion

deathdeath

CC

TimeTimeLowLow

High

Func

tion

death

Advance Care Planning

Often the concerns and wishes we have for end-of-life care emerge as the situation unfolds, or are never discussed, rather than making intentional choices, based on thoughtful discussions in advance about quality of life, values, risks and benefits, and goals of care

We often make the most difficult decisions in a time of crisis, under a shadow of grief, or at a time when communication between those involved may be challenging

Conversations - not just forms

• Advance Care Planning is …

• “A process of coming to understand, reflect on, discuss, and plan for a time when you cannot make your own medical decisions and are unlikely to recover from your injury or illness.”

» Making Choices™ » Planning in Advance for Future Healthcare Choices» Gundersen Lutheran Medical Foundation

Purpose of POLST (Physician Orders for Life-Sustaining Treatment)

To provide a mechanism to communicate

patient preferences for end-of-life

treatment across treatment settings

What is POLST ?• A Set of Actionable Medical Orders

• Can be completed by any healthcare professional, but must be signed by a licensed physician*

• Complements, but does not replace, advance directives

• Voluntary use, but provides consistent recognized document

*In some states a nurse practitioner or physician assistant may sign the POLST form

The Surprise Question

• Would you be surprised if your patient with advanced cancer died in the next year?”

• If the answer is “No”, likely appropriate for POLST

• Connections between POLST model and Cancer Plan Objectives 15.1 – 15.7