Honoring Choices Wisconsin: Improving Advance Care Planning Across the State John Maycroft, M.P.P. Wisconsin Medical Society Wednesday, September 18, 2015 The name Honoring Choices Wisconsin is used under license from East Metro Medical Society Foundation.
Objectives At the end of this presentation, attendees should be able to: Understand Advance Care Planning as a process Learn the basics of spreading advance care planning in clinical settings and the community Know HCW s role in implementation
Advance Care Planning Advance Care Planning is a process of understanding, reflecting on, and discussing future medical decisions, including end-of-life preferences.
Advance Care Planning Includes: Understanding your health care treatment options Clarifying your health care goals Weighing your options about what kind of care and treatment you would want or not want Making decisions about whether you want to appoint a health care agent or complete an advance directive Communicating your wishes and any documents with your family, friends and health care provider
60% Don t want to burden 56% Have not communicated their wishes
70% Prefer to die at home 70% die in an institution
80% would like doctor to talk about EOL 7% say doctor has talked about EOL
75% of physicians not aware that AD existed 23% of patients have completed AD 82% of patients say ADs important
Question Based on your experience, what are good illustrations of the value of advance care planning and advance directives?
The La Crosse Experience 90% of decedents have an advance directive 99.4% of those decedents advance directives were found in the medical record where they died. 99.5% of treatment decisions were found consistent with instructions Dramatic effect on Family Satisfaction (LADS 2007-08, Detering et al. 2012)
Advance Care Planning Facilitation What is your understanding of advance care planning? What are your experiences with sudden illness? Who would you want to speak for you if you couldn t speak for yourself?
What are your goals in case of a severe neurologic injury? What religious, cultural, or personal beliefs might influence your preferences? How do you record them?
Stages of Advance Care Planning Over the Lifetime of Adults First Steps Create POAHC and consider when a serious neurological injury would change goals of treatment Next Steps Determine what goals of treatment should be followed if complications result in bad outcomes Last Steps Establish a specific plan of care expressed in medical orders using the POLST paradigm Healthy adults who have not planned between ages 55 and 65 Adults with progressive, life-limiting illness, suffering frequent complications Adults whom it would not be a surprise if they died in the next 12 months
Facilitations must be: Offered Scheduled Conducted Documented in an advance directive Entered consistently into the medical record
It s About the Conversation!
Mission To promote the benefits of and improve processes for advance care planning across the state, in health care settings and in the community.
The Clinical Approach Key Elements: 1. System Design 2. ACP Facilitation Skills and Education 3. Community Engagement 4. Continuous Quality Improvement
Participants Agree to: A shared approach, including trial implementation A shared language around advance care planning Share lessons Not compete around advance care planning Contribute financially
Clinical Trials Offer facilitated ACP conversations to a targeted patient demographic Utilize Respecting Choices training and principles Learn lessons for broader implementation
The Clinical Pilot Approach Fall Design & Implementation training Winter Facilitators trained March 1 September 1 Trial implementation October Sharing the Experience Conference Wider implementation
Outcomes and Measures 1. >50% of people invited to participate will agree to schedule an appointment with a facilitator. 2. 100% of people who complete an ACP discussion will have this conversation documented. 3. >50% of people who participate in a conversation will complete a written plan.
Outcomes and Measures 4. Participants will rate the conversation 3 or greater on a 5 point scale. 5. Agents will feel more prepared to make healthcare decisions for the patient as a result of the conversation. 6. Facilitators will be able to integrate ACP conversations into their routines of care as measured by time spent on ACP.
Outcomes and Measures 7. Facilitators will become more confident in their facilitation skills over time. 8. Facilitators will provide feedback on the advance directive document. And the stories!
Building a Vocabulary Glossary & Style Guide Standardizing across participants Working with reporters & media Moving away from focus on documentation
Standardized Documentation and Storage Although legally acceptable ADs can take many forms, standardization will improve community understanding and participant engagement. Advance care plans must follow the patient, and be accessible in the medical record
Round 1 Participants: 1. Community Care, Inc 2. Fort HealthCare/Rainbow Hospice/Jefferson Co. ADRC 3. ProHealth Care 4. Group Health Cooperative-SCW 5. Meriter Health Services 6. UW Hospital & Clinics 7. William S. Middleton Memorial Veterans Hospital
Round 2 Participants: 1. ADORAY Hospice and Home Care 2. Agrace Hospice and Palliative Care 3. Aspirus 4. Baldwin Area Medical Center 5. Froedtert & The Medical College of Wisconsin 6. Mayo Health System-NW Wisconsin 7. St. Croix Regional Medical Center 8. ThedaCare 9. Watertown Regional Medical Center
Round 3 Participants: 1. Amery Regional Medical Center 2. Bellin Health 3. Hudson Hospital and Clinics 4. Mercy Health System 5. Reedsburg Area Medical Center 6. Westfields Hospital & Clinic
HCW is not: Encouraging one decision over another Legislation POLST (Physicians Orders for Life Sustaining Treatments)
Community Engagement Faith Communities Multicultural Organizations Senior Groups Disability Community LGBT Organizations
Faith Ambassador Programs Clergy speak to audiences in faith and other settings Group facilitation model, or attendees can sign up for individual facilitation AD connected to individual s medical home
Hub and Spoke Model Multiple points of contact: ADRCs, allies, Society staff, clergy, media, others can all introduce individuals to the concept Pool of facilitators available to meet with patient organized by area hospice, local coalition, or other association AD completed and connected to individual s medical home
INTRODUCTION FACILITATION DOCUMENTATION MEDICAL RECORD
Media Outreach Television Internet Social Media Newspapers Consider the Conversation
Challenges Collaboration Physician and Stakeholder Understanding Lack of common language Wisconsin-Specific Legal Barriers Competition for Time / Resources Community Awareness Building
Lessons for the Movement Importance of Medical Society s convener role Strategic mapping Fundraising Woodwork effect Coalition Building
Rewards Better care, healthier patients, happier families & providers Positive change in a difficult political environment Interest from 20 states across country & politics Fun, meaningful work
Know your rights, obligations and protections Under Wisconsin law, a physician cannot be held civilly liable or charged with a crime for following the wishes of a patient or the decision of a Health Care agent pursuant to a valid Advance Directive or Power of Attorney for Health Care. A Health Care Agent has priority over any person, other than the patient, to make health care decisions for the patient.
Know your rights, obligations and protections A physician will not be immune from liability for withdrawing or withholding life sustaining treatment or a feeding tube if, in the physician s professional judgment, doing so will cause the patient pain or discomfort that cannot be medically controlled. A physician is not required by law to follow an advance directive or the decision of a Health Care Agent, but if a physician refuses to do so, he or she must make reasonable attempts to transfer the patient to another physician who will follow the directive or decision.
Know your rights, obligations and protections At all times, the wishes of a patient who is not incapacitated supersede any written document or decision of another.
Q&A