What If?! Advance DirecZves in PRIMARY CARE.

WhatIf?!
AdvanceDirec3vesinPRIMARYCARE.
JamieM.SchnellBlitstein,BSN,RN
UniversityofNevada,Reno
Objec3ves
•  Understandcostvs.benefitinend-of-life(EOL)
care.
•  Increaseknowledgeofevidence-basedprac3ce
regardingthediscussionofEOLplanning.
•  UnderstandtypesofAdvanceDirec3veusedin
TheStateofNevada,explainingthedifference.
•  Understandnextofkinandthedurableofthe
PowerofAVorney.
•  UnderstandPOLSTandtheAPRN.
•  Pa3entandproviderresources.
Evidence-basedPrac3ceandaMonetaryBlackHole.
BACKGROUND
OneMoreThing?!
•  Tellmeaboutyourpast
medical/surgicalhistory?
•  Haveyoubeenthevic3m
ofabuse(physicalor
emo3onal)orviolence?
•  Tellmeaboutyoufamily/
homeenvironment?
•  Tellmeaboutyourfamily
medicalhistory?
•  Haveyouexperienced
anySOBorchestpain?
•  Tellmeaboutyourdiet?
•  Doyouexercise?
•  Doyouusealcohol?
Drugs?
•  Whatmedica3onsare
youtaking?
•  Tellmeaboutyoursex
life?
•  ANDTHELISTGOESON…
DOYOUHAVEANADVANCE
DIRECTIVE
or
DOYOUKNOWWHATYOUWANT
TOHAPPENIFYOUSTOP
BREATHINGORYOURHEARTSTOPS
BEATING?
DOESYOURFAMILYKNOW?
Ifyouwereunabletospeakfor
yourself,whowouldyouwant
tospeakforyou?
Haveyoutalkedtothatperson?
WhydoIcare?
•  DeathiscurrentlyaPUBLICHEALTHCRISIS.
•  Deathcosts125billiondollarseveryyear.
•  Medicare:decedentscost$38,975,survivorscost
$5,993.
•  Itispossibletoslashthisspending.A2011
studyfoundthatAdvanceDirec3veswere
associatedwith:
•  LOWERMedicarespending.
•  LOWERlikelihoodofdyinginthehospital.
•  HIGHERuseofHospiceCare.
(Adamopoulos,2013;deChesnay&Anderson,2012;IOM,2014;Morhaim&Pollack,2013;Nicholas,Langa,Iwashnya,&Weir,
2011;Wang,2012)
WhatdoesDEATHlookliketoday?
•  ThenumberofpeopledyinginICUscon3nues
torise.
–  WhyarewedyinginICU?
•  80%ofpeoplewantapeacefuldeathathome.
–  IOMreportsthatmorethan¼ofpa3entshavegivenNO
THOUGHTtotheirEOLwishes,includingthoseover75.
–  AstudyoutofMarylandfoundthatwhile60%ofrespondents
wanttheirwishescarriedout,butthatonly1/3had
completedanAdvancedDirec3ve.
•  End-of-lifecareisrifewithaggressiveinterven3onswith
minimalclinicalbenefit,whichincreaseanxietyandpainfor
dyingpa3entsandtheirfamilies.
WhyPrimaryCare?
•  TrustedProvider.
•  Morelikelytoseethisproviderin3mesof
health.
–  Thisdiscussionisbeststartedbeforeend-of-lifeis
looming.
•  Consistency.
–  Furtherques3onsmaybeaddressedonfollow-up.
(Bernacki,&Block,2014;Evans,&Crane,2013;IOM,2014)
OurPa3entsRelyonUs.
•  Nursesremainthe#1trustedprofession.
•  Someoneneedstostartthisconversa3on.
•  EvidenceplacestheresponsibilityinPRIMARY
CARE.
–  Conversa3onsarenothappening.
•  Rao,Anderson,Lin,&Laux(2014)foundthatonly
26.3%oftheir7946respondentsreportedhaving
advancedirec3ves.
•  Mostfrequentlycitedreason?Lackofawareness.
–  Lackofprovidereduca3onisalsoafactor.
(Gallup,2015;IOM,2014)
WhatifandEvidence-BasedPrac3ce.
•  EvidencesupportsEOLplanninginPRIMARYCARE.
•  Educa3onaboutadvancedirec3vestooccurat
milestoneages:
–  16,newdriver
–  21,drinkingage
–  MarriageorDivorce
–  Birthofchild
–  ChangeinHealthStatus(subsequentencounter)
–  ChangesinLivingSitua3on(movinginwithfamily/assisted
living/nursinghome)
–  Re3rement
(IOM,2014)
AToughQues3on.
•  Culturaltaboo.
–  Asproviderswe’realreadyaskingtough
ques3ons.
–  Pa3entswantustoask.
•  Tipsforstar3ngtheconversa3on:
–  Makeitrou3ne.
–  Frametheques3on.
–  Offersupport.
–  Haveinforma3on.
–  Givethem3me.
(Bernacki,&Block,2014;IOM,2014;Granek,Krzyzanowska,Tozer,&MazzoVa,2013)
ThingstoknowaboutAdvanceDirec3vesinTheStateofNevada.
THELAW
LivingWillorDeclara3on
•  “Declara3on”isthepreferredterminologyin
underNevadaStateLaw.
•  TheDeclara3on:
•  Stateswhattypesofcareonewantsordoesnotwantin
caseapersonbecomesunabletomaketheirownmedical
decisions.
•  Benefit:
–  Allowsapa3enttobeveryspecificaboutwhatthey
want.
–  Greatinconjunc3onwithDurablePowerofAVorney
forHealthcare.
(NevadaCenterforEthicsandHealthPolicy,2016;NevadaRevisedStatues,n.d.)
LivingWillorDeclara3on
•  Disadvantage:
–  Alonemaynotensurewishesarecarriedout.
–  Mispercep3onsexist:
•  ManybelieveNRSstatesnextofkinisconsultedunless
thereisaPowerofAVorney(C.Nelson,personal
communica3on,January2016).
–  NRS449.640statesthat“theaVendingphysicianmay
considerotherfactorsindeterminingwhetherthe
circumstanceswarrantfollowingthedirec3ons.”
–  Thereisno“civilorcriminalliabilityforfailureto
followtothedirec3ons”ofadeclara3on.
(NevadaCenterforEthicsandHealthPolicy,2016;NevadaRevisedStatues,n.d.)
DurablePowerofAVorneyfor
Healthcare.
•  ADurablePowerofAVorneyforHealthcare(POA)isa
documentthatlegallydesignatesanotherpersonasan
“agent”tomakehealthcaredecisionsifonebecomes
unabletomakethem.
•  Restric3onsonwhomaybedesignatedas“agent”,per
NRS162A.840:
–  Aperson’sproviderofhealthcare.
–  Anemployeeofaperson’sproviderofhealthcare.
–  Anoperatorofahealthcarefacility
–  ANEMPLOYEEOFAHEALTHCAREFACILITY
*unlessoneofthesepeopleisspouse,legalguardian,or
next-of-kintotheprincipal.
(NevadaCenterforEthicsandHealthPolicy,2016;NevadaRevisedStatues,n.d.)
DurablePowerofAVorney
•  Benefit:
–  LivehumantoenforceEOLwishes.
–  LegallymakesdecisionsINSTEADofnext-of-kin.
–  POAisunderstood,moreclearlyenforcedthanaDeclara3on,
andwidelyunderstoodtooverridenext-of-kindecisions.
–  POAformincludes“StatementofDesires”similarto
Declara3on.
•  Disadvantage:
–  Cancreatetensioninfamilies.
–  Requirescommunica3onforaccuraterepresenta3onofEOL
wishes.
–  POAdoesNOThavetosignanagreementandcanrefusewhen
calledupon.
(NevadaCenterforEthicsandHealthPolicy,2016;NevadaRevisedStatues,n.d.)
ThePOAForm!
Next-of-Kin
•  InNevada:
1.  Spouseofthepa3ent.
2.  Adultchild,orMAJORITYofadultchildrenreasonably
availableforconsult.
3.  Parentsofthepa3ent.
4.  Siblingofthepa3ent,orMAJORITYofthesiblings
reasonablyavailableforconsult.
5.  Nearestotheradultrela3vebybloodoradop3on.
•  Familysitua3onsmaystronglyaffectthe
benefitofaPOA.
(NevadaCenterforEthicsandHealthPolicy,2016;NevadaRevisedStatues,n.d.)
Photocredit:AlbanyPixretrievedfromhVp://www.mirror.co.uk/news/
weird-news/gran-has-do-not-resuscitate-taVooed-152251
Do-Not-ResuscitateOrder(DNR)
•  AnorderwriVenbyaPhysicianthattellsmedical
professionalsNOTtoperformCPRifaperson
stopsbreathingortheirheartstopsbea3ng.
–  Benefits:
•  WhendisplayedproperlythisordermaypreventEMSfrom
star3ngCPRinthefield.
•  Mayreduceunnecessaryinterven3onatEOL.
–  Disadvantage:
•  Ordermustbephysicallypresenttobehonored.
–  DNRtaVoosareNOTLEGAL(Smith&Lo,2012).
(NevadaCenterforEthicsandHealthPolicy,2016;NevadaRevisedStatues,n.d.)
POLST
•  ThePhysicianOrderforLife-Sustaining
Treatment(POLST)isanAdvanceDirec3ve
similartoaDNRorder,butcanalsoinclude
ordersregarding:
–  Transporttoahospital
–  Mechanicalven3la3on
–  Administra3onofan3bio3cs
–  Ar3ficialNutri3on
–  OrganDona3on
(NevadaCenterforEthicsandHealthPolicy,2016;NevadaRevisedStatues,n.d.)
POLST
•  Benefits:
–  Ac3onablePhysicianOrderintendedtobehonoredby
ANYhealthcareprofessionalinANYhealthcaresevngor
thepa3ent’shome.
–  Islegallybinding.
–  Canbeusedbyanyreques3ngpa3entinNevada.
•  Disadvantages:
–  Intendedforseriouslyill,regardingcurrentcare.
–  Aphysicianmayevaluatethepa3entandrecommendnew
ordersconsistentwithcurrentstatusandgoals,butMUST
consultthepa3ent,ormakea“reasonableaVempt”to
consulttheirrepresenta3veandaVendingphysician.
–  DoesnotnegateneedforotherAdvanceDirec3ves.
(NevadaCenterforEthicsandHealthPolicy,2016;NevadaRevisedStatues,n.d.)
POLSTandtheAPRN
•  Currently,inNevada,POLSTcannotbesigned
byanAPRN. –  Thereisworkbeingdonetoremedythis.
(NAPNA,2016;NevadaRevisedStatues,n.d.)
Canitbebilled?
•  Consulta3onsforAdvancedCarePlanning
(ACP)CANbebilledwithMedicareasof
January1,2016!
–  IncludedintheAnnualWellnessVisit.
–  99497isa30minuteconsulta3onwithapa3ent,
theirfamily,ortheirsurrogate.
–  99498isanaddi3onal30minutes.
•  Coverageunderotherinsurancesisdifficultto
ascertain.
(NevadaPOLST,2016)
Wheretodirectpa3entsandplacestolearnmore.
RESOURCES
ForProviders.
•  AriadneLabs:hVps://www.ariadnelabs.org/
programs/serious-illness-care/resources/
•  Polst.org
•  Nevadapolst.org
•  4hourCEU:hVp://www.nursingceu.com/
courses/442/index_nceu.html
•  NevadaRevisedStatutes:hVp:/
leg.state.nv.us/nrs/
nrs-449.html#NRS449Sec600
Video
•  hVps://www.youtube.com/watch?v=AB_Wluva1dY
Understanding
•
What is your understanding now of where you
are with your illness?
•
•
worst
preferences
•
• No decisions necessary
today
FOR EXAMPLE:
(right column)
Prognosis
•
preferences
•
Goals
most important goals?
Worries
•
the future with your health?
•
Guide
you can’t imagine living without them?
Family
to discuss together)
ForPa3ents.
•  NevadaLivingWill:hVp://www.nvlivingwill.com/
register.php
•  *Pa3entInforma3ononNevadaStateLawConcerning
AdvanceDirec3ves(printablePDF):hVp://
www.pebp.state.nv.us/
informa3onNV_Law_Advanced_Direc3ves.pdf
•  PamphletsprintedbyRenown,St.Mary’s,Northern
NevadaMedicalCenter,CarsonTahoe,andCarsonValley
MedicalCenter.
•  HardChoicesforLovingPeople:hVp://www.amazon.com/
Hard-Choices-Loving-People-Life-Threatening/dp/
1928560067
•  Acoupleofgamestoplay:
–  hVp://mygizofgrace.com/(costs$24.95)
–  hVp://www.gowish.org/(freeonlineversion)
There’sanAPPforthat.
•  Thereareatleast7availableforiPhone.
–  AdvanceDirec3vesbyStanfordMedicine.
–  MyHealthcareWishesPro($3.99)
–  HonorMyDecisions
–  MyDirec3vesMobile
–  LeavingWell
–  HowtoWriteaLivingWillGuide
–  MyOwnVoice
VideofortheRoadJ
•  hVps://www.ted.com/talks/
peter_saul_let_s_talk_about_dying#t-780175
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