Advance Care Planning: Just Do It!

Advance Care Planning: Just Do It! And why your Nurse Practitioner is smarter than you Monica Williams-Murphy, MD Board Certified Emergency Physician Huntsville Hospital Medical Director for Advanced Care Planning and End of Life Education Programs American College of Emergency Physicians End-of-Life Taskforce Author, It s OK to Die Board of Directors, Hospice Family Care and the Los Angeles Hospice at Anam Cara Clinical Assistant Professor, UAB School of Medicine, Huntsville

None Disclosure

When Everything is in Order Peace is the Product Dr. Murphy, My dear Mother recently passed away and her and my Step Father s attention to the smallest details: legally, medically, spiritually, and emotionally, for her (end of life and death), undoubtedly made this a graceful and uplifting experience for our entire family. I am on a mission, now, to attempt to provide the same thing for my own children B. Teague

Outline: Advance Care Planning (Just Do It!) The American Advance Care Planning Dilemma: the 90-70 dilemma What holds us back from Advance Care Planning? Understand CPT codes/payment and the vital role of the nurse practitioners What patients need to know about Advance Directives When Time is Short: LEAD Understand patient safety issues related to medical directives Outline population health imperatives for ACP The Product of Advance Planning is Peace and A Good Death

The American Advance Care Planning Dilemma: The 90-70 Dilemma Huge GAP between what people want for end-of-life care and what they actually receive: 90% of people wish to die at home 70% of people actually die in institutions Only 20-30% of Americans have Advance Directives

Local Results of the 90-70 Dilemma Trends and Variations in End of Life Care for Medicare Beneficiaries with Severe and Chronic Illness, 2011, Dartmouth Atlas Report Vhttp://www.dartmouthatlas.org/downloads/reports/EOL_Trend_Report_0411.pdf

Results of 90-70 Dilemma Trends and Variations in End of Life Care for Medicare Beneficiaries with Severe and Chronic Illness, 2011, Dartmouth Atlas Report Vhttp://www.dartmouthatlas.org/downloads/reports/EOL_Trend_Report_0411.pdf

Advance Care Planning Readiness The public is ready for Advance Care Planning 89% of the public says doctors should discuss end of life care issues with their patients, though relatively few (17%) say that they have had such discussions with their doctor. (Kaiser Family Foundation Health Tracking Poll, Sept 2015)

What holds everyone back from Advance Care Planning? Taboo topic in modern conversation, death is failure We are disconnected in time, space and emotions We have faith in medical technology Doctors don t talk about it, and aren t trained to

Advance Care Planning= Cost Savings Cost Savings of robust ACP regional programs already well documented: Lacrosse Wisconsin where 90% of adults have ACPs, MSBP in last two years of life is 61% less than national average.

Advance Care Planning Reimbursement Codes remove a barrier to discussions CMS funded the following two Medicare codes Jan 2016: CPT code 99497 documents a discussion of ACPs with the patient, a family member or a surrogate for up to 30 mins. (at least 16 minutes) ($75-85) CPT code 99498 documents an additional 30 mins (at least 46 minutes) (additional $70-75) NOT ONE TIME CODES, can be repeated multiple times. CANNOT be billed on SAME days as some Critical Care Codes (99291-99292, 99468-99476, 99477-99480) Doctor or APP with own Medicare Provider Number/within their scope of practice WHY YOUR NURSE PRACTITIONER SHOULD OWN THIS!

Advance Care Planning Reimbursement Codes remove a barrier to discussions So, what must be documented? Anything related to Advance Directives, Code Status Discussions Surrogate Decision-Making Medical Choices NO RULES..YET!

Different Discussions for Different Care Timelines Long Range, ACP and Patient Education Mid-Range, Navigating Age and Illness, Palliative Care Professionals Proximate Decisions, Admission, ICU, Emergency Department

Long Range Discussions: 9 Things to explain to patients about Advance Directives (And get paid to do so!) 1. The Big Picture Map of Life -course of illness 2. Explain what happens if you don t plan 3. Advise how to talk to loved ones 4. Why and how to choose (and educate) your healthcare agent 5. Determine the range of power of your healthcare agent 6. Your Healthcare Instructions (On Your Own Terms!) 7. Who should have a copy of your advance directive? 8. How often should your advance directive be updated/reviewed? 9. Where should an advance directive be stored?

1. The Big Picture- Map of Life or prognosis and course of illness

2. Explain What Happens if You Don t Plan Hell Hath No Fury Loudest person often runs the show Guilt-burden immense for uninformed decision-makers You are VERY UNLIKELY to get care On Your Own Terms

3. Advise How to Talk to Loved Ones Conversation Starter Kit Holidays Family Meetings Letters Videos Lead by example (Audience idea: Have everyone read and sign your advance directive)

4. Explain Why and How to Choose (and Educate) your Healthcare Agent

4. Why Choose an Healthcare Agent? Multiple Choice Question % of us (total population) will be unable to make medical decisions for ourselves near the end of our lives? A. 25% B. 35% C. 50% D. None of the above (David Wendler PhD, Director of Vulnerable Populations at the National Institutes of Health s Department of Bioethics. )

4. How to Choose an Healthcare Agent(s) Do they have any medical knowledge? Are they willing to put your needs and desires before their own? Do you trust them? Does your extended family trust them? Do they have good leadership and decision-making skills? Would you trust them to take care of someone you love?

4. How to Educate your Healthcare Agent(s) Outline your present level of health and quality of life. Discuss your feelings about death, dying, and illness. What level of physical independence is important to you? What level of mental activity is important to you? Discuss your specific healthcare instructions with them and the range of powers you are granting them.

5. Determine the Range of Power of Your Healthcare Agent Only And Other

6. Your Healthcare Instructions (On Your Own Terms!)

6. Your Healthcare Instructions (On Your Own Terms!) Artificial Nutrition IV Fluids CPR Ventilator Dialysis Antibiotics Life Prolonging Treatments Comfort Focused Care Any medicine or therapies used to create comfort Trial Period Your Own Terms

7. Who Should Have a Copy of Your Advance Directive? Your Healthcare Agents Your Healthcare Providers Anyone in the family who might show up at your bedside with an opinion Your attorney, if you have one The mailman?

8. How often should your advance directive be updated or reviewed? Annually if you are healthy Every 6 months if you have a chronic or terminal illness With a sudden change in healthcare status (ex: heart attack) Hospitalization or transition from one care setting to another Healthcare Agents need to be updated at the same intervals

9. Where Should Your Advance Directive be Stored? The only copy should NOT be in your safety deposit box or in a dusty drawer! Electronic Health Record at your preferred hospitals Your Doctor s office On your refrigerator door or in your freezer in a marked envelope Online with a secure storage site.

Proximate Discussions- STAT! (Hospital Admission, ICU, Emergency Department) LEAD Mnemonic for quick guidance and recall of crucial steps needed to support patients and surrogate decision-makers in discussions and decisions in the acute care setting: Lead with an emotional connection: I want to talk with you like you are my family member. Because I care about all of my patients, I want to make sure you are getting the type of care you want Explain Risks, Benefits and Alternatives to medical decisions to be made in setting of present prognosis Ask/Answer questions Document conversation/time spent and write orders supporting decisions Copyright, Monica Williams-Murphy, MD. 2016. May be freely reproduced with proper attribution

Mirarchi FL, Doshi AA, Zerkle SW, Cooney TE. TRIAD VI: how well do emergency physicians understand physicians orders for life sustaining treatment (POLST) forms? J Patient Saf. 2015;11:1-8. Mirarchi FL, Cammarata D, Zerkle SW, Cooney TE, Chenault J, Basnak D. TRIAD VII: do prehospital providers understand physician orders for life-sustaining treatment documents? J Patient Saf. 2015;11:9-17.

The Silver Tsunami and ACP Baby Boomers Turning 65 Silver Tsunami ARE YOU READY???

End of Life Peace is the product of Advance Care Planning (A Good Death) Dr. Murphy, My dear Mother recently passed away and her and my Step Father s attention to the smallest details: legally, medically, spiritually, and emotionally, for her (end of life and death), undoubtedly made this a graceful and uplifting experience for our entire family. I am on a mission, now, to attempt to provide the same thing for my own children B. Teague

A Good Death is the NEW STANDARD of CARE.

Additional References The Gallup Organization: Knowledge and Attitudes Related to Hospice Care. Princeton, NJ: Gallup Organization: Sept 1996 http://www.pbs.org/wgbh/pages/frontline/facing-death/facts-andfigures/ 2005 CDC statistics Emanuel L, von Gunten C, Ferris F. (2000) Gaps in End-of-Life Care. Archives of Family Medicine. 9. 1176-80. National Hospice and Palliative Care Organization, 2012: Facts and Figures: Hospice Care in America Cardiopulmonary Resuscitation on Television Miracles and Misinformation Susan J. Diem, M.D., M.P.H., John D. Lantos, M.D., and James A. Tulsky, M.D. N Engl J Med 1996; 334:1578-1582 June 13, 1996 DOI: 10.1056/NEJM199606133342406 Out-of-Hospital Cardiac Arrest Surveillance --- Cardiac Arrest Registry to Enhance Survival (CARES), United States, October 1, 2005--December 31, 2010 http://www.cdc.gov/mmwr/preview/mmwrhtml/ss6008a1.htm Public expectations of survival following cardiopulmonary resuscitation.jones GK, Brewer KL, Garrison HG. Acad Emerg Med. 2000 Jan;7(1):48-53. Ira Byock, The Four Things That Matter Most, FREE PRESS,A division of Simon & Schuster, March 2004 Williams-Murphy M and Murphy K. (2011) It s OK to Die. www.oktodie.com Kehl K (2006). Moving Toward Peace: An analysis of the concept of a Good Death. American Journal of Hospice and Palliative Care. 23, 277-286. http://external.bangordailynews.com/projects/2015/06/hospice/