MEDICATION RECONCILIATION by liaoqinmei

VIEWS: 8 PAGES: 27

									     Advance Directives
Promoting Patient Autonomy and Informed
   Health Care Decisions Through HIE




                                          1
Objectives

• Understand the concept of advance care planning
• Increase awareness of the complexity and risk associated with
  sharing documents.
• Define best practice in obtaining advance care wishes
• Describe opportunities for improving use of advance care
  documents and conforming treatments to patient preferences.
• Participants will use “Advance” and “Advanced” correctly.




                                                                  2
Pt. Self Determination Act (1991)
• The right to make or advance their own health care decisions
• The right to accept or refuse medical treatment
• The right to make an advance health care directive

  Required hospitals and nursing facilities to ask patients if they had
  an advance directive.
  Hence, the HL 7 message for AD was simple: Yes/No. and a free
  text field
• Now contains some structured text (e.g.: “DNR”) and support for
  CDA
• CCD supports sufficient information to allow recipient facilities to
  engage a patient or family on advance care planning and current
  treatment orders.



                                                                          3
So why?
• If they are intended to promote autonomy
• why did hospitals choose admission clerks as
  their agent for collecting and documenting the
  presence of the document?




                                                   4
Documents vs. Orders
Documents                     Orders
• Designation of Health       • Do Not Resuscitate
  Care Proxy                  • Do Not Hospitalize
• Living Wills                • Do Not Intubate
• Instruction Documents       • No Tube-feeding
   – Terminal Illness
                              • No Artificial Feeding or
   – Highly Dependant State
                                Hydration
   – Advanced Cognitive
     impairment               • No Antibiotics
• Personal Values
• All of the above
Key Terms

•   End stage condition
     • Defined by states
     • In Maryland, it is described as dependant for care in every ADL
•   Terminal Illness
     • Incurable with imminent prognosis for demise.
     • Hospice eligibility is considered 6 months or sooner
•   Medical Decision Making Capacity
     • Ability to process information and respond appropriately
     • Sufficient cognitive capacity to understand nature of condition,
       treatments, risks, benefits and prognosis
•   Competent
     • Minimum requirements to qualify as witness or party to contract
     • Determined by a judge

                                                                          6
General Concepts

People can refuse treatments
If a person has lost decision making capacity and does not have a legal
    proxy, there is a surrogate by default defined in statute
Default surrogates may have limitations on their ability to refuse certain
    treatments (CPR, tube feeding, etc).
Court ordered guardians are necessary to limit care in cases of futility.
Providers may refuse to provide futile care to people even if they insist
    on having it, but they must be given an opportunity to seek that care
    elsewhere.
There is always one more daughter somewhere. Usually in California.



                                                                         7
Common Features of Proxy
Documents
• Active on signature or with loss of medical decision making capacity
  (physician declaration) or incompetence (judicial process)
• May require
   • One or two physicians
   • Added qualifications in evaluating decision making capacity
   • Face to face encounter with patient
   • Duration of impairment
• Certification of Decision Making Capacity may be appended
• Health Care Agent and Alternate if not “readily available”




                                                                     8
Health Care Agent or DPOA

Current practice is to name in Proxy document
  Prior practice was Durable Power of Attorney for Health Care
Can be named in any document meeting the standard.
Can be given verbally to a health care provider.




                                                                 9
Living Will

Among the first widely accepted advance directive
Very limited circumstance
Requires a certification of terminal illness.
Most people already experience significant suffering before activate
   living will.




                                                                       10
Instruction Documents

More helpful
Specific interrogatory for each area of heroic measures
Guides care team as to the persons attitudes

Results in a granular discussion with scenarios within categories of life
  sustaining measures to reflect a persons wishes more completely.




                                                                        11
MOLST

• Medical Orders for Life Sustaining Treatments.
   • Widely adopted
   • Harmonized to some degree in most states
   • Required as part of admission to nursing facility in some states
        • Fulfills patient rights requirements in NF regulations
In some states, the MOLST can be honored across settings.




                                                                        12
Advance Directive Documents

OTHER CHALLENGES


                              13
Activation

Most documents are not active upon signature
Trigger events and requirements defined in document
Receiving facility may or may not have all the information and
   supporting documentation to activate a document.




                                                                 14
Versioning and Chronology

The legal landscape has changed over time.
  Old documents are still valuable to demonstrate a persons beliefs at
  the time about heroic measures.
People may execute multiple documents for a variety of reasons
  Family issues
  Change in condition
  Change in standards of practice
People often rescind Advance Directives when they get acutely ill or are
  confronted by Emergency Services Personnel or Intensivists.
Advance directives may not apply to certified staff acting independently.



                                                                       15
Credentials

Licensed physician
   May be a move to add NPP’s
Expertise in cognitive function
   Psychiatrist
   Neurologist
   Internist/FP
   Geriatrician
Expertise in PVS
Document face to face contact.




                                  16
MDM at Time of Declaration

Actually not required to document
Assumption is the participation in the document creation is done in
   good faith by a person with intact decision making capacity.




                                                                      17
Actionable Orders

In order for a physician to write a DNR, for example, in acute setting, on
   incapacitated person
   Assess nature and duration of incapacity
   Assess nature and treatment of acute problem requiring
   hospitalization
   Assess risk and burden of CPR
   Assess benefit of CPR
   Review prior declarations of patient regarding CPR
   Identify legal proxy named in valid document, activated appropriately
   Discuss above and confirm DNR
Some states allow a Emergency Services DNR form which can be
   honored in ambulances and ED’s.


                                                                        18
Optimal workflow

 Plan in Advance
 Multiple conversations between health care provider informed by
  applicable research and the current realities of care and a patients
  agent who is present
 Informed by a legacy of documentation regarding the patients
  wishes about health care decision making in the past
 Documents and conversations stored and indexed for retrieval.
 Important metadata, especially status of patient, agent, LST wishes
  and contact information can be extracted.
   – Requires seamless coordination of clinical process with
      documentation systems.
Remember




           20
Continuous Process on Advance
Care
 Experience in a CCRC




                                21
Results




          22
Rochester RHIO - Patient Portal
This is what patient sees when they click on the “what
does it look like” link
This is what patient sees when they click on the “more
information” link. Link opens in separate tab.
FORMS are available in the list on the side bar mid-way down the page.
Conclusions

Advance Care Process is a key component to effective and appropriate
   utilization of acute care services.
Focus and accountability improve compliance
Clinicians will need more than documents to efficiently manage
   emergency decisions.
Structured metadata requires alignment with Ambulatory, Hospital and
   Long Term Care health records.
Several States (Oregon, Rochester (NY), Arizona, others) have
   Registries.




                                                                   26
WHO HAS THE FIRST
QUESTION?




                    27

								
To top