Impact of The Changing Nature of End-of-Life Care

Dr_Christopher_Pile_changing_nature_of_end_of_life_carePresenter: Emily
Guest: Dr. Christopher Pile
Guest Bio: He is the Chair and Medical Director of the Virginia POST (Physicians Orders for Scope of Treatment) Collaborative Executive Committee, and works for the Good Samaritan Hospice in Roanoke, Virginia.

Segment Overview: We discuss the impact of the changing nature of end-of-life care on the healthcare profession, and the importance of transforming the existing systems to support alignment with patient choices.



Health Professional Radio – Nature of End-of-Life Care

Emily: You’re listening to Health Professional Radio.  This is Emily, and my guest is Dr. Christopher Pile.  He is the chair and medical director of the Virginia POST Collaborative Executive Committee, and he works at the Good Samaritan Hospice in Roanoke, Virginia.  Dr. Pile and I have had a previous discussion about what the patient experience is in palliative care, and what the goals are of the palliative care provider, in helping the patients to understand what the realities of the medical profession are in terms of what can be offered and what their wishes might be. Dr. Pile, thanks so much for speaking with me again.

Dr. Christopher Pile: Thank you for the opportunity, Emily.

Emily: I’d like to talk about what the physicians experience is with your work.  Now, tell me a little bit about POST – the Physician’s Orders for Scope of Treatment.  What is that?

Dr. Pile: Well, it’s really a document that serves as a communication tool.  It is part of a larger effort throughout the United States called the POLST Paradigm.  That’s POLST – Physician’s Orders for Life-Sustaining Treatment.  We changed our acronym to POST.  There’s many acronyms throughout the country.  In the US, each state’s health care laws are unique.  There isn’t a unified health care law, so each state has to approach it differently.

What this allows us to do is to take a conversation that happens probably over a period of time between a health care provider, might be a physician, could be a physician extender or nurse practitioner, physician’s assistant.  Also could be trained…other disciplines: social work, clergy, nursing.  After they’ve completed a lengthy discussion, the patient may feel it’s time now to ensure that those decisions that they have made are then enacted and executed at the time that they’re necessary.

Emily: I see.

Dr. Pile: A POST allows for those orders to be signed at that time by both the provider, again a physician or a physician extender, and the patient both sign the actual medical orders to be enacted if the patient loses capacity.  The reason we needed to do that is we see the benefits of making decisions in advance of the crisis, because once the crisis happens, it can be hard to get decision makers, and physicians need some guidance.

 We have advanced directives living wills.  Unfortunately, they were not able to actually impact care at the bedside, because care at the bedside is actually driven by physician’s orders.  The physician may not have enough direction from a living will, because it wasn’t specific enough for them to interpret, and it wasn’t really changing outcomes.  There was a disconnect between what patients were expecting and the care they receive.

What we really want to do is re-connect that, so patients receive the care that they wish.  The best way to do that again is to have physician’s orders that are specific and drive the care that’s given.

Emily: I see.  If I’m correct about this, an advanced directive is something that any adult at any age over 18 could sign and say, “In the event of… I would like to receive any treatment possible” or “I would not like to be resuscitated.”  But a POST form is different, because it is for someone in the state of health that they are today.  Is that correct?  If I am not terminally ill, it wouldn’t be appropriate for me to fill out a POST form?

Dr. Pile: Right, exactly.  An advanced directive gives you guidance of the hypothetical possible situations in the future.  They also can also direct who would be…either identify who you would like to speak for you in the event you lose capacity.  Every adult again should have one, at least specify who should we ask if you can’t answer.  But for a healthy person again, it’s hard to predict what future events might happen to me, what future care, and I can’t really make an informed decision…

 Somebody with advanced progressive disease, it’s easier to predict what interventions they may require in the future.  In fact, they might have actually experienced those interventions.  They might have received CPR.  They might have been on a ventilator.  They might have been in the ICU.  It’s no longer hypotheticals.  For instance, they have that knowledge base, having a discussion in advance of an anticipated event.

It’s much more anticipated if somebody who has heart disease, if they’re going to have [indecipherable 05:07].  That’s predictable.  We should plan for it and not respond to it, like it’s a medical emergency, unpredictable.  That’s the goal.

Emily: I see.  Is there a clear delineation between who is too healthy for POST and who is ideal?  Or is there some grey area?

Dr. Pile: Again, I think we’ve really focused in Virginia.  That`s a debate within the advanced care movement. We’ve really felt that it’s a  varied subset of patients with advanced disease.  Ultimately again, a couple of key points: the first is it’s patient driven.  The patient needs to initiate whether they want a POST, not a physician.  In other words, after the discussion goes on, the physician may suggest, “Would you like to document that?”  It’s totally patient-driven.   It’s not physician-driven.  The physician doesn’t fill out a POST for our patient.

The patient fills it out in collaboration with a physician.  They need a physician’s signature to actually make it effective.  The first thing is it’s patient-driven.

Emily: I see.

Dr. Pile: The other process is that, again, it only goes into effect when the patient is incapacitated.  It doesn’t bind the patient into making their own decisions, but it’s for us if they lose capacity.  It can be changed. Again, it’s there as a safety net.  That again, the goal is to ensure that we have this direct connection between patients’ expectations and wishes, and the care they receive.  Advance directives haven’t been able to make that connection.  This is, I would say, a progression of advance directives.

Emily: Is this appropriate for a patient who is, say, suffering from dementia, or in some way unable to speak for themselves?  How do you allow a primary spokesperson to help draft something like a POST form, and then prevent a family member in the operating room from saying, “Do everything you can”?

Dr. Pile: Okay.  Well, a POST form can be completed by either the patient, and if they lose capacity, then it can be completed by their surrogate decision maker, whoever they designated.  It can be by either.  Again, if there’s a conflict between a POST and – there would be never be a conflict between POST and the patient if they completely [inaudible 07:58] a decision maker. If there are other members of the family that have a disagreement, again, legally, we’re driven by first patients and then the surrogate decision maker.

There are certain decisions, it’s a very important role, but it’s always the one identified family member.

Emily: I see.  Have you found that there is a need for additional collaboration with the intake forms in the hospital?  Say, a patient comes in.  They have a POST form.  Are the intake forms that they’re filling out appropriate to serve the needs of a patient with a POST form?

Dr. Pile: Well, that gets back to a systems-wide approach.  That’s really one of the strengths of POST is that it forces the community to now create a system approach to patient care at the end of life.  There is coordination between the care providers, and there could be multitude of care providers, in the home or in the nursing facility.  There’s care providers within the transport community as a patient is transported from facility to facility, and then at each facility.

 That’s where POST, the strength of not only developing the form for that direct patient contact is creating the system behind that, before the form, and that’s then getting all these parts of our health care system together, and developing policies and procedures that are standardised so we know how to respond.  Again, we have an excellent system that’s been developed for a medical emergency.  It’s 911.  People know that number as a caregiver.  We know what happens when we call that.  There’s protocols.

There’s protocols for nurses, EMS, emergency transport, hospitals.  Again, that system developed organically, it was over time.  What we’re trying to do with POST is a similar response because that same patient who has cardio-pulmonary arrest may want the interventions of an [indecipherable 10:12].  But they may not, and you can’t just have a negative system.  There has to be a system on how do we respond to that person who doesn’t want that type of interventions.  They’re still physically there…they’re experiencing symptoms, they need health care intervention.

It’s just, again, the goal would now be we have to be responsive, we have to be quick, we have to be timely, we have to be skilled in reducing suffering.  That’s where we haven’t really developed the alternative systems.  Everything’s default when you see somebody in distress to dial 911.  That activates a certain system with certain goals.  We have to develop this parallel system for other patients.  That’s really, I think the strength of the POST, is not necessarily the document, but the whole planning process that we’ve been working on throughout this country.

Emily: How long would you say that this has been developing?  Where are we at in terms of how many years has this been going on?

Dr. Pile: Well, it started in Oregon in late ‘90s.

Emily: Okay.

Dr. Pile: It’s been going on for quite some time.  We’ve modeled our program off of the POLST paradigm in the Oregon health system, and then it spread throughout the country.  Almost all states have some form of development.  Then, in Virginia, we modeled our form after that, and in the process of having discussions with patients and families, educating the advanced care planning facilitators, educating physicians, we’ve been through program called Respecting Choices, and that’s [indecipherable 11:56] medical system across Wisconsin.

It’s that the combination of the form and also again, having the training to have informal discussions with patients to complete the form.

Emily: Are you seeing an increase in efficiency or an increase in improved patient and family outcomes in the hospitals already?  Have you been experiencing success in Virginia?

Dr. Pile: Yes, yes.  There’s a pilot project.  We started in Roanoke Valley, and now it’s spreading throughout the state.  We have 13 different pilot projects, and universally, there’s been acceptance first from the medical community so hospitals, long-term care facilities, home help agencies, hospices, have seen the need and patients and families and physicians.  I sense that there’s certainly a need.

 As we’ve done the pilot project, we have seen a big improvement and again, with the outcomes we really measure our patients’ satisfaction with the process.  They’ve been very satisfied in having these discussions.  Then, we look for alignment of care received versus care documented in the POST form.   The POST form is what we call a neutral form.  It has a whole range of therapies; you can request all interventions on the form: resuscitation, ICU, artificial hydration, or artificial nutrition.  All these you can spell that, that’s what I request.

Or you can have the other end of the spectrum, and decline these interventions.  Again, it’s a value you need to form, and what we’ve found is there’s a very strong alignment, and that’s the key, and that’s where we have improvements [inaudible 13:52] patients receiving the care and families are seeing the care that they expected, when again, the end of life comes.

Emily: I see.  I see.  Well, thank you very much.  This is Emily with Health Professional Radio.  I’m speaking with Dr. Christopher Pile from the Good Samaritan Hospice in Roanoke, and the Virginia POST Collaborative.  Dr. Pile, thank you so much for speaking with me today.

Dr. Pile: My pleasure, Emily.