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
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.
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 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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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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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
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