San Francisco POLST Coalition Update: Mainstreaming Palliative and End of Life Care October 24, 2012 Physician Resource, San Francisco Medicine, SFMS Member end-of-life care, Palliative Care, POLST 0 By Jeffrey Newman, MD, MPH, and Steve Heilig, MPH “When it came time for my family to discuss end-of-life care issues for my father, the POLST framework was invaluable. It greatly facilitated early and useful dialogue and allowed us to come to a very comfortable consensus despite a longstanding history of disagreement over his earlier long-term care issues.” —Keith Loring, MD, FACEP, emergency physician and SFMS board member There is an ever-increasing focus on health care provided toward of the end of life, for multiple reasons. For one thing, there is growing awareness that end-of-life care has often fallen short of what is desirable and possible, and thus the growth of palliative care, new models of long-term care, and so on. A generation of baby boomers is bringing their high expectations for self-determination into their later years. New policies will force attention to cost issues as reimbursement becomes more tied to quality and use standards. The modern medical ethics movement can be seen at least in part as a “patient empowerment” trend, and one way this has been codified into practice is through the use of various advance directives used to document patient preferences for care. The documents have been available for decades, but still only a minority of patients completes them. And it must be admitted that more forms are not a panacea—but they can help immensely when patients might no longer be able to tell clinicians what they desire. The SFMS and some key partners have been working with grants from the Metta Fund and the California HealthCare Foundation to support a number of activities increasing conversations among patients with advanced illness, their physicians, and other health care professionals. Advanced directives and POLST documents are more widely used in nursing homes, hospitals, and ambulatory care. Again, however, most patients in the “last chapter” (operationally defined as life expectancy of less than a year) still do not take advantage of these opportunities. A recent survey of EOL attitudes and practices among California adults reveals that while 82 percent believe that it is important to have wishes in writing, only 23 percent have done this; 47 percent would like to have “the conversation” with their physician (61 percent of those over 65); and 70 percent would like to die at home, but this occurred in only 32 percent of deaths in 2009.1 Another recent study of POLST implementation among nursing homes in California indicates that POLST use has become common, especially in areas served by a POLST Coalition, as in San Francisco. We and other Coalitions have assessed the POLST process in nursing homes and offered suggestions for quality improvement.2 Steven Pantilat, MD, a leading figure in palliative medicine at UCSF, has offered the following practical suggestions to increase availability and access to palliative care: Establish organized programs at all hospitals, open access to hospice without giving up advanced illness management, expand the supply of physician and nurse specialists, educate all clinicians in basic palliative care, and educate the public through a marketing campaign.3 Widespread programs to reduce hospital readmissions should also focus on advanced illness and EOL issues that underlie many of these cases. The San Francisco Department of Aging and Adult Services (DAAS) has been awarded a Medicare Community-Based Care Transitions Program (CCTP) contract to provide services through a hospital-to-home transitional care model focused on lowering hospital readmissions. This collaborative model includes DAAS, nine additional community-based organizations, and eight hospitals in San Francisco County. Services include coaching, care coordination, and a support services package of meals, homecare, and transportation. We are exploring opportunities to incorporate assessment of needs for palliative and EOL services and referral. Among the many ways San Francisco physicians can support this and other hospital readmission efforts is to provide early follow-up appointments for patients after hospitalization—and, when appropriate, initiate referrals to palliative care, advanced illness management, and hospice. And whenever appropriate, consider using a POLST form with your patients—for the third time in this journal, the actual form is included here for your convenience. Your patients, their families, and some of your colleagues will be grateful. For more information, see POLST California's website. For a copy of the POLST form, click here. Dr. Jeff Newman is director of the Sutter Health Institute for Research and Education, adjunct professor at UCSF, and a former SFMS board member. Steve Heilig is on the staff of the San Francisco Medical Society and is coeditor of the Cambridge Quarterly of Healthcare Ethics. References 1. Lake Research Partners and the Coalition for Compassionate Care of California. Final Chapter: Californians’ Attitudes and Experiences with Death and Dying. http://www.chcf.org/publications/2012/02/final-chapter-death-dying#ixzz28ve6oIpt. 2. Wenger NS, Citgo J, OMalley K. Implementation of physician orders for life-sustaining treatment in nursing homes in California. J Gen Intern Med. August 2012. http://link.springer.com/article/10.1007%2Fs11606-012-2178-2. 3. Pantilat SZ. When it’s the right care, more is better. Arch Intern Med. 2012; 172(15):1172-3. Postscript At last month’s annual CMA meeting, the following new statewide policy was adopted: INCREASING UTILIZATION OF POLST ORDERS Authors: Jeffrey Newman, MD; Leslie Lopato MD, Adam Schickedanz, MD That to increase and improve use of Physicians Orders for Life- Sustaining Treatment (POLST), CMA encourage physicians to become educated about all aspects of the POLST form and to integrate discussions about, and utilize, POLST in all appropriate instances where medical services are provided to patients at the end-of-life. Comments are closed.
