Thursday, March 23, 2017

Quality & Safety Consideration for Patients with a POLST or Living Will

Do We Ask for Permission to Treat First? Or Treat first & Ask Questions Later?

Figure 1: This resuscitation card links to a video by the patient explaining their care preferences:https://vimeo.com/user44599014/review/188926708/25b475b740 The password is: 911.

As we are educated on the ethical & financial concerns surrounding end-of-life care, we are informed by Institute of Medicine that end-of-life care is broken and accounts for $170 billion in annual spending (1). This projection will exceed $350 billion in less than 5 years. To better align patient wishes, living wills & POLST (Physicians Orders for Life-Sustaining Treatment) are necessary documents and processes. Whether you like them or not they are here to stay are we need to assure provider competency.  Additionally, Medicare now reimburses for advance care planning conversations in the office or via telemedicine. In the past, Physicians have tried to embrace living wills and more recently, the POLST paradigm has emerged to the national forefront. POLST & POLST-like processes have grown rapidly, which has outpaced the ability of states to educate to ensure the safe & effective utilization of this process.  Both living wills & POLST have limitations but are good documents with many benefits and are very much required to allow patients to preserve their autonomy (2,3).  How these documents are applied by others, in clinical situations, such as critical illness, has led to the unintended consequences of both “over” & “under” resuscitation.  By way of their success, we have essentially introduced a new patient safety risk which has no quality oversight.  As a result, we now must recognize these risks & act to protect patient wishes and outcomes.

Living wills require interpretation. POLST does not and is an immediately activated medical order set. So can we correctly interpret living wills and can we trust the POLST becomes a question. Most living wills are created by attorneys years in advance prior to the onset of medical conditions.  The POLST are completed by other providers (ex. Social Workers or admission nurses) & signed by physicians who may or may not have been involved in the conversation.  So, how do frontline physicians (such as Pre-hospital, Emergency Medicine, Trauma and Hospitalist physicians) interpret these during a brief interaction? Specifically, Emergency Medicine physicians do not know these patients or families & have no established trusts or report, yet, within seconds, are expected to understand the patient’s wishes to either accept or decline life-saving interventions based upon a form.  Of what is often documented, the “Full Code” appears understood.   However, with a do not resuscitate order, things are less clear.  Further, with POLST, there are many combinations of treatment options, which make the water muddier.

The TRIAD (The Realistic Interpretation of Advance Directives) studies have questioned whether or not providers understand what to do with Living wills, do not resuscitate & POLST orders.   It questions whether we are trampling on patient wishes to better control costs.  We need to figure out who is better off with a living will vs. a POLST.  We need to set quality standards & abide by them universally for both the living will & POLST.   More importantly we need to standardize Goals of Care conversations, so they are balanced & can accurately predict the patient’s wishes.  That information then requires the ability to be conveyed to a totally different & disconnected medical provider in a safe & effective manner that ensures no patient safety risk to the actual patient.

Volandes, Wilson & El-Jawahri have performed pioneering work with clinician to patient video. It has been shown that clinician to patient educational videos can help patients make informed decisions about CPR (4,5,6).   So, could we then utilize patient to clinician video testimonials to help providers make informed medical decisions for patients in a safe & effective manner?   In March 2017, the Journal of Patient Safety released the TRIAD VIII Study.  This was a Multicenter Evaluation to Determine If Patient Video Testimonials Can Safely Help to Ensure Appropriate Critical vs. End of Life Care.   From this work, we can now say that we can do things better to ensure we get it right for patients.    Figure 1 is just an example of how we can bring patients back into the actual decision-making process.

With patient video clarification, we can now hear from patients, in their voice and expressions, when they are critically ill & receive their guidance rather than providers guessing after reviewing a form that may or may not have been completed correctly. We know that forms when not fully completed lead to errors in treatment(8). We know that POLST forms can be discordant with patient wishes (9).  Resuscitations are complex & physicians need to know what to do initially in the first seconds to 15 minutes of an event.  Furthermore, the physicians comfort in the process to trust and act on what is documented is of paramount importance. Paper forms at present do not do this well or provide the necessary level of assurance to Physicians.  We still need POLST & living wills but we also need to hear from the patients to clarify the patient’s wishes. With emerging technologies, we also need to be able to incorporate patient to clinician video in a safe & cost effective manner.

In conclusion, we have a safety problem with living wills & POLST documents. TRIAD VIII presents an opportunity to do better. The traditional treat first and ask questions later approach is already being challenged by the development of malpractice litigation. To do what is right for patients, we need to embrace both living wills & POLST & be sure we set quality standards for their completion & understanding.  We must also investigate patient to clinician video and technologies to allow the clinicians to hear from the patient to accurately guide their care.

References:
  1. Institute of Medicine. Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life. National Academies of Sciences, Engineering, Medicine. September 17, 2014. Available at: http://www.nationalacademies.org/hmd/Reports/2014/Dying-In-America-Improving-Quality-and- Honoring-Individual-Preferences-Near-the-End-of-Life.aspx. Accessed January 3, 2016.
  2. Nicholas LH, Langa KM, Iwashyna TJ, et al. Regional variation in the association between advance directives and end-of-life Medicare expenditures. JAMA. 2011;306:1447-53.
  3. Fromme EK, Zive D, Schmidt TA, et al. Association between Physician Orders for Life- Sustaining Treatment for Scope of Treatment and in-hospital death in Oregon. J Am Geriatr Soc. 2014;62:1246-51.
  4. Volandes AE, Paasche-Orlow MK, Mitchell SL, et al. Randomized controlled trial of a video decision support tool for cardiopulmonary resuscitation decision making in advanced cancer. J Clin Oncol. 2013;31:380-6.
  5. Wilson ME, Krupa A, Hinds RF, et al. A video to improve patient and surrogate understanding of cardiopulmonary resuscitation choices in the ICU: a randomizedcontrolled trial. Crit Care Med. 2015;43:621-9.
  6. El-Jawahri A, Paasche-Orlow MK, Matlock D, et al. Randomized, controlled trialof an advance care planning video decision support tool for patients with advanced heart failure. Circulation. 2016;134:52-60.
  7. Mirarchi FL, Cooney TE, Venkat A, et al. TRIAD VIII: Nationwide Multicenter Evaluation to Determine Whether Patient Video Testimonials Can Safely Help Ensure Appropriate Critical Versus End-of-Life Care. J Patient Saf. 2017 Feb 14 [Epub ahead of print] PubMed PMID: 28198722.
  8. B Clemency et al. J Am Med Dir Assoc 18 (1), 35-39. 2016 Sep 28. Decisions by Default: Incomplete and Contradictory MOLST in Emergency Care.
  9. Hickman SE, Hammes BJ, Torke AM, Sudore RL, Sachs GA. The Quality of Physician Orders for Life-Sustaining Treatment Decisions: A Pilot Study. J Palliat Med. 2016 Nov 1 [Epub ahead of print].

Disclosures:
Ferdinando L. Mirarchi, D.O. has disclosed that he is the Principal Investigator of the TRIAD research series. He has an independent medical practice that focuses on advance care planning. He further discloses that his patients receive an ID Card depicted in this publication.

Kate Aberger MD, was a study site Principal Investigator for the TRIAD VIII study and has no further disclosures.


by: Ferdinando L. Mirarchi and Kate Aberger

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