1/10/2017. ADVANCE CARE PLANNING in Older Adults. Disclosures. Objectives. I have no financial or conflicts of interest

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1 ADVANCE CARE PLANNING in Older Adults Kathleen Hodgkins, MSW Ingham County Medical Care Facility Francis A. Komara, D.O. Michigan State University College of Osteopathic Medicine January 21, 2017 Disclosures I have no financial or conflicts of interest Objectives Define Advance Care Planning in older adults. Define decisional capacity and competence. Identify differences between advance directives; living wills, DPOA for health care directives, DNR, DNH. Physician Role 1

2 Advance Care Planning The process of planning for future medical care with the goal of helping patients receive medical care that is aligned with their preferences, especially in the setting of serious illness or as the end of life approaches. Ongoing process that can change over time. What is an advance directive? An advance directive is a written document in which you specify what type of medical care you want in the future, or who you want to make decisions for you, should you lose the ability to make decisions for yourself. Expression of our values, wishes and goals. Voluntary Advance Directives, Michigan State LongTerm Care Ombudsman Program,2017 2

3 Advance Care Planning In 1995, 20% of hospitalized patients had an advance directive Only 12% of these patients had been counseled by a physician. Many physicians and surrogate decision makers were unaware of patients preferences. Recent studies show as many as 70% of elderly decedents had an advance directive, although the presence of the AD had little effect on hospitalization rates within 2 years of death. Advance Directives (one component of ACP) include: Medical durable power of attorney for health care Living wills DNR/DNI DNH Preferences into medical care plan: Role of artificial nutrition and hydration, antibiotic use. Advance Care Planning The process involves conversations with family, friends, clinicians over time. More than an one-time documentation of advance directives. Outcome is completing an advance directive, but important to focus on the conversation/process. 3

4 Important Questions Who would you want to make decisions for you if you couldn t make them yourself? What would be the goals of treatment if you permanently lost the ability to meaningfully know who you were, who you were with, or where you were? Do you have any religious, personal, or cultural views that would affect treatment choices? Respecting Choices, First Steps Facilitation Training Living Well What present or future experiences are most important for you to live well at this time in your life? What fears or worries do you have about your illness or medical care? Who or what helps you when you face serious challenges in life? Respecting Choices, First Steps Facilitation Training Advance Care Planning: Benefits Ability to identify, respect and implement an individual s wishes for medical care, especially in the absence of decision-making capacity during serious illness or near the end of life. Ability to manage personal affairs while able, peace of mind, less burden on family. Reduction in stress, anxiety and depression in surviving family members. Improved patient satisfaction and quality of life. 4

5 Advance Care Planning: Benefits Decreased use of intensive medical interventions at the end of life. Implementation of preferences to limit unwanted medical treatment (avoid hospitalization or CPR) Fewer in-hospital deaths, more hospice use, lower Medicare costs, with advance directives specifying comfort-oriented end-of-life care. What is a durable power of attorney for health care? A durable power of attorney for health care, also known as a health care proxy or a patient advocate designation, is a document in which you appoint another individual to make a medical treatment and related personal care decisions for you. Legally binding Must be at least 18 years old The patient advocate can make decisions for you only when you become unable to participate in medical treatment decisions yourself. Advance Directives, Michigan State LongTerm Care Ombudsman Program,2017 5

6 May be temporary as with a stroke, or permanent as with dementia. The patient advocate may also authorize the withholding or withdrawal of treatment, as long as the patient expressed in a clear and convincing manner that the advocate is authorized to make such decisions. May include your authorization to withhold or withdraw food and water administered through tubes. You can also express your wishes concerning other types of care, desire not to be placed in a nursing home and desire to die at home. Advance Directives, Michigan State LongTerm Care Ombudsman Program,2017 If no specific wishes concerning medical treatment are expressed, then the patient advocate must make decisions about medical care in what they see as you best interest. The DPOA must be in writing, signed by you, and witnessed by two adults who are Not family members, not your doctor or proposed patient advocate, not an employee of a health facility or program where you are a patient. If an interested person disputes whether the patient advocate is acting in your best interests, or has the authority to act in your behalf, the interested person may petition the local probate Advance Directives, Michigan State court to resolve the dispute. LongTerm Care Ombudsman Program,2017 What is a living will? 6

7 A living will is a written document in which you inform doctors, family members and others what type of medical care you with to receive should you become terminally ill or permanently unconscious. Only takes effect after a doctor diagnoses you as terminally ill or permanently unconscious and that you are unable to make or communicate decisions about your care. Not legally binding in Michigan Advance Directives, Michigan State LongTerm Care Ombudsman Program,2017 DPOA vs. Living will The durable power of attorney focus is on WHO makes the decision. The focus of a living will is on WHAT the decision should be. The living will is limited to care during terminal illness or permanent unconsciousness, while a patient advocate may have authority in temporary disability. A living will may be honored without the presence of a third person. You might state I authorize all measures be taken to prolong my life. or Do whatever is necessary for my comfort, but nothing further. Advance Directives, Michigan State LongTerm Care Ombudsman Program,2017 Advance Care Planning Terms & Definitions Advance care planning (ACP)- Process of considering and communicating health care values and goals over time. Advance directive- Legal document describing preferences for future care and appointing a surrogate to make health care decisions in the event of incapacity. Medical durable power of attorney- Legal document that appoints an agent to make future medical decisions. Becomes effective only when the patient becomes incapacitated. Surrogate decision maker or health care proxy- A decision maker that makes medical decisions when the patient becomes incapacitated and the individual did not previously identify a medical durable power of attorney. 7

8 Advance Care Planning Terms & Definitions Surrogate decision maker or health care proxy- A decision maker that makes medical decisions when the patient becomes incapacitated and the individual did not previously identify a medical durable power of attorney. Most states use a hierarchy system to designate a health care proxy, whereas a few states appoint a proxy that is agreed on by all interested parties. Living will- Documents an individual s wishes prospectively regarding initiating, withholding, and withdrawing certain life-sustaining medical interventions. Effective when the patient becomes incapacitated and has certain medical conditions. Advance Care Planning Terms & Definitions Cardiopulmonary resuscitation (CPR) directive or do-not-resuscitate (DNR) order- Documents preferences to refuse unwanted resuscitation attempts. Orders for life-sustaining treatments (ie, Physician Orders for Life-Sustaining Treatment (POLST)- Order set that translates patient preferences for life-sustaining therapies into medical orders. Primarily intended for seriously ill people with life-limiting or terminal illnesses and patients in long-term care facilities. Portable and transferrable between health care settings. Decision-making Capacity A person s ability (capacity) to make decisions is often assessed through conversation with that person. When assessing cognition through conversation, it is important to note the following: 1. Communication 2. Culture 3. Circumstances 4. Choices 5. Consequences 6. Consistency 8

9 Capacity 1. Communication- are language barriers or hearing difficulties interfering with your assessment? 2. Culture- are cultural considerations interfering with your understanding of the person? 3. Circumstances- does the person understand their circumstances? 4. Choices- is the person able to state their choices regarding care? 5. Consequences- can the person state the consequences of choices that they make regarding care. 6. Consistency- is the person s choice consistent with their values? With their previous behavior? Are choices consistent over time? Is the decision voluntary and not coerced? Surrogate decision makers Which family member can make the decision? A general family consent statute sets forth a priority for family members; first, the spouse; second an adult child or children; third, parents; fourth, siblings. Important that any decision maker/patient advocate understands the responsibility and the individual s wishes. Advance Care Planning is a multistep process 1. Assess readiness and identify barriers Have you ever completed an advance directive, living will, DPOA? Is it up to date? ACP helps me work with you and your family to understand how to plan your medical care in case you lose the ability to make decisions. Can we talk about this? Are there things that you worry about when you think about planning for future medical care? What keeps you from thinking about these types of things? 9

10 ACP process 2. Identify surrogate decision makers Identify a trusted person as a surrogate decision maker to help clinicians apply overarching goals to specific clinical situations in the event that the patient loses decisional capacity. Is there someone you trust to be involved in making medical decisions on your behalf if you cannot? What have you talked about? What would you tell this person is important about your medical care? Flexibility gives your decision maker leeway to work with your doctors and possibly change your prior medical decisions if something else is better. Are there decisions that you don t want your loved one to change? ACP process 3. Asking about patient s values related to quality of life Evaluate the individual s values and priorities in life and discuss what constitutes an acceptable quality of life. Have you had any previous experience with making decisions about medical care during a serious illness? Can you tell me about that? When (you were hospitalized; or a loved one died), did this situation change your thoughts about what is important to you in the future or what would be unacceptable, where you wouldn t want to live like that? ACP process 4. Document ACP preferences. Document expressed care preferences in an advance directive document (medical power of attorney, living will); ensuring written plans are communicated, stored, and retrievable. Since you ve chosen (loved one) to help make decisions on your behalf if you re very sick and unable to talk with me, I recommend that you complete the medical power of attorney form to make it official. Can you bring in your advance directives? It helps me, the clinic and the hospital know what is important to you if you are very sick. 10

11 ACP process 5. Translate values and preferences into current medical care documents (MI-POST form, CPR directive and life-sustaining treatments, limited interventions (hospitalization, antibiotics) in general scope of care options. Role of artificial nutrition and hydration. Role of hospitalization and/or outpatient services such as hospice. You told me that if you were not able to interact with your family and friends, your life would not be worth living. Is that correct? Many patients who feel as you do, opt not to have life support. Based on what you told me, I d like to go over the MI-POST form. ACP process 5. (cont) At this point, medical intervention in no longer providing you with benefit. I recommend we focus on treatments that maximize quality of life. Time ACP takes time it s an ongoing/continuous conversation How might a physician be able to start the process without taking so much time? Language matters Approach as a favor to you Can you do me a favor and think about who you trust to be your voice if there was a time you couldn t speak? Focus on living, not dying Is there someone in the office that can continue the conversation? Start the conversation, and then allow a social worker or nurse in the office to finish it. 11

12 Reimbursement: Medicare and BCBSM list reimbursement for the following codes Medicare Office 80.79, Facility BCBSM Office 89.78, Facility Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate. Reimbursement Medicare Office 70.90, Facility BCBSM Office 78.19, Facility Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; each additional 30 minutes (List separately in addition to code for primary procedure) Reimbursement Advance care planning services are reported for the discussion and explanation of advanced directives by a physician or other qualified health care professional. These services are timebased services that do not involve any active management of problems during the course of the face-to-face service between the provider and a patient, family member, or surrogate and may be reported on the same day as another E/M service. Report for the first 30 minutes of advance care planning and for each additional 30 minutes. The patient must be present. 12

13 Contacts for ACP Upper Peninsula Kate LaBeau of Upper Peninsula Health Plan Southwest corner of state Melinda Graham Gruber of Lakeland Health System Southeast corner of state Jim Kraft of Henry Ford Health System Northwestern corner Stephanie VanSlyke of Munson Health System Northeastern and east- central Ashley Hunt of Mid-Michigan Health West-central Carol Robinson of Making Choices Michigan MIPOST and overall statewide programs Carolyn Stramecki of Honoring Healthcare Choices Michigan [ contact only: cstramecki@honoringhealthcarechoicesmi.org] References Lum HD, Sudore RL, Bekelman DB. Advance Care Planning in the Elderly. Med Clin N Am 2015; 99: Michigan Department of Health and Human Services, Aging and Adult Services Agency, Michigan Long- Term Care Ombudsman Program.AdvanceDirectives ectives_website_503870_7.pdf Respecting Choices (2015) First Steps Facilitation Training. Gundersen Lutheran Medical Foundations, Inc. 13