VNAA Blueprint for Excellence PATHWAY TO BEST PRACTICES

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Baldwin Dawson
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1 VNAA Blueprint for Excellence PATHWAY TO BEST PRACTICES Patient and Caregiver Engagement: Treatment Preferences VNAA Best Practice for Hospice and Palliative Care

2 Information sharing and support of patient/caregiver participation in identifying Treatment Preferences that impact the patient/caregiver experience of care are not only central to hospice philosophy but are now a part of hospice quality reporting. 2

3 Why Treatment Preferences Dying patients who are given the opportunity to express their preferences regarding life-sustaining treatment are more likely to receive care consistent with their values. (CMS 2014). CMS now requires hospices to initiate a discussion with patients or caregivers about Treatment Preferences within five days of admission. 3

4 Definition of Best Practices 1. The patient/responsible party is asked about their preference regarding the use of CPR, life-sustaining treatments other than CPR and Hospitalization. 2. Hospice staff should visit multiple times and bring up multiple discussions about treatment preferences to ensure patient and caregiver support of the decisions. 4

5 Critical Interventions/Actions Introduce the range of end of life decisions at the initial visit. CMS requires documentation that the discussion took place or was refused. Hospices should review and reaffirm any pre-admission documentation about treatment preferences. Ensure the patient/caregiver understand the implications of various choices. 5

6 Critical Interventions/Actions - 2 Any discussion of CPR should include the benefits and burdens associated with the procedure. (Dunn, 2011 pp 11-16) Lives are saved each year with CPR. However patients with the least chance of survival (less than 2%) are those with multiple medical problems; cannot live independently or have a terminal disease. CPR can cause a frail patient s ribs to be broken, a lung or spleen punctured or brain damage if the patient has been without oxygen for some length of time 6

7 Critical Interventions/Actions - 3 Any discussion of artificial hydration (feeding tubes and IV s) should include the benefits and burdens associated with the procedure. (Dunn, 2011,pp17-23) Feeding tubes and IV s can provide needed nutrients for a patient who can no longer eat. Feeding tubes and IV s have risks such as pneumonia, ulcers, infections and the need to restrain a patient who repeatedly tries to remove the tube. In the dying patient there are several benefits of NOT using feeding tubes or IV s 7

$(Dunn, 2011, pp39-40) Patients can benefit from an hospital admission to get symptoms under control or treat an acute condition such as a fracture.$

8 Critical Interventions/Actions - 4 Any discussion of hospitalization should include the benefits and burdens associated with that intervention. (Dunn, 2011, pp39-40) Patients can benefit from an hospital admission to get symptoms under control or treat an acute condition such as a fracture. Burdens to consider include the increased possibility of infection, use of restraints or sedation, aggressively treating any condition because that is the ordinary practice and increased possibility of burdensome diagnostic testing. 8

9 Critical Interventions/Actions - 5 Coach caregivers on ways to prevent hospitalizations if hospitalization is not the preferred plan Other treatment preferences typically assessed include preferences for nutrition, hydration including IVs and feeding tubes, opioid pain management and stopping other treatments not directly related to patient comfort. There is no CMS comprehensive list of life-sustaining treatments. If patient is unable to communicate, caregiver surrogates and documented advance care plans can provide guidance. 9

Critical Interventions/Actions - 6 Treatments that might become optional also include: Radiation or chemotherapy in an effort to cure the disease.

10 Critical Interventions/Actions - 6 Treatments that might become optional also include: Radiation or chemotherapy in an effort to cure the disease. Antibiotics used to treat an infection like pneumonia unless necessary to relieve pain Most diagnostic testing, especially those that are painful like drawing blood. Surgery unless absolutely necessary to promote comfort of the patient. 10

11 Critical Interventions/Actions - 7 Treatment preferences can only be discussed once the goals of medical care are agreed upon. Goals should be discussed within the context of What outcome can we reasonably expect from the medical treatment, given the current condition of the patient? (Dunn, 2011, p7) Goals can change as the patient s condition changes. 11

12 Critical Interventions/Actions 8 In the patient s final days ensure that the patient and caregiver are supported in carrying through with stated preferences. (Chochivoc, 2005; NCP, 2013) Utilize a tool to implement the treatment preferences discussion requirements of CMS in a systematic way. No standard tool is available that can be universally applied to all patient populations (Selman, 2011). 12

13 Measurement 1. Percent of patients who were asked about their preference regarding CPR before or within 5 days of admission. (HIS F2000) 2. Percent of patients/responsible party who were asked about their preference regarding other life sustaining treatments before or within 5 days of admission. (HIS F2100) 3. Percent of patients/responsible party who were asked about their preference regarding hospitalization before or within 5 days of admission. (HIS F2200) 13

14 Resources The Conversation Project This is a national initiative started by lay people and advised by the Integrated Health Institute, a national health care improvement organization. The Conversation Project encourages people to have conversations with their loved ones about end of life preferences, and provides tools to support those conversations. It also includes a guide for patients to discuss end of life with their physician. Physician Orders for Life Sustaining Treatment POLST is a national initiative to promote end of life planning for people with serious illness or facility. POLST initiatives have been developed in multiple states in order to ensure compliance with state laws on advance care planning. The program encourages conversations between patients, their caregivers and their health care professional to promote shared decision making about treatments at the end of life and documentation of the patient s wishes. The POLST website includes information on end of life discussions and links to state programs where forms and written materials can be found. Bischoff KE, Sudore R, Miao Y, Boscardin WJ, Smith AK. Advance care planning and the quality of end-of-life care in older adults. J Am Geriatr Soc Feb;61(2): Castillo LS, Williams BA, Hooper SM, Sabatino CP, Weithorn LA, Sudore RL. Lost in translation: the unintended consequences of advance directive law on clinical care. Ann Intern Med Jan 18;154(2): Data collection tools and guidance available in the HIS Manual: Guidance Manual for Completion of the Hospice Item Set (HIS) v effective July 1, Reporting/Downloads/HIS-Manual.pdf National Consensus Project For Quality Palliative Care. Clinical Practice Guidelines For Quality Palliative Care Available at: 14

The POLST Conversation POLST Script

The POLST Conversation POLST Script The POLST Script provides detailed information in order to develop comfort and competence when facilitating a POLST conversation. The POLST conversation utilizes realistic