Physicians often don’t have the time or the training necessary to steer patients through end-of-life care planning decisions. It’s a process that’s fraught with difficulty – patients and family members often have to weigh legal considerations, financial pressures, and complex medical decisions. There are many factors that can complicate the planning process, including feelings of denial, grief, or guilt and conflicting religious or cultural beliefs surrounding death.
End-of-life planning is appropriate not only for the elderly, but for the terminally ill (both adults and minors) and for trauma cases with a poor or uncertain prognosis. A well prepared nurse case manager can smooth the process by helping families discuss patient preferences and document their wishes – and there’s a promising new tool that all case managers and geriatric nurses should know about it. Known as Physician Orders for Life-Sustaining Treatment (POLST), it turns individuals’ treatment preferences into actionable medical orders that can move from one care setting to another.
Too much end-of-life care?
According to the Dartmouth Atlas Project, which tracks health care trends, over 80 percent of cancer patients say they want to avoid hospitals and intensive care units during the terminal phase of their illness. Yet fewer than one-third of Americans have written out their preferences for end-of-life care, according to the National Hospice and Palliative Care Organization (NHPCO).
Too often, the result is that family members and doctors feel a duty to do “everything possible” to extend the patient’s life – at an enormous cost to the health care system. As reported by The Medicare Newsgroup, in 2011, 28 percent of Medicare dollars (about $170 billion) was spent on care during the last six months of patients’ lives. Another article makes the business case for end-of-life planning, stating, “There is growing evidence that investments in advance care planning, palliative and hospice care pay off, not only in improved patient and family member satisfaction but also in greater longevity and cost savings.” For example, a 2006 study by Duke University found the average Medicare savings per hospice patient is $2,300.
It’s no wonder, then, that payers are turning to case managers to manage costs and help patients navigate end-of-life choices. An article in the Wall Street Journal reports:
Insurer Aetna began using nurse-care managers to help manage both Medicare and commercially insured patients with terminal illness in 2004, using telephone consultations with patients, doctors and families to, among other things, ensure advance directives are in place and complied with. As a result of the program, a higher proportion of members elected hospice care compared to prior years, which was associated with a decrease in the use of acute care, intensive care and emergency services, particularly for Medicare Advantage beneficiaries. Precise cost reductions couldn’t be determined for patients in Medicare because it paid the costs directly, Aetna said. But in the commercially insured population, the program led to a net medical cost decrease of 22% compared to a control group not using the care-management services.
POLST: A new form of advance directive
Traditional advance directives, sometimes known as living wills, are problematic in many ways. They are written in legalese, making them difficult for the average person to understand, and require a plethora of steps to legitimize them, including witness signatures and notarization. They are usually vaguely worded, stating patient preferences in the broadest of terms – which means family members are often left to make a difficult judgment call when the patient can no longer speak for himself. Since they are usually stored with other legal documents, they often cannot be found when they are needed.
This is where POLST comes in. The POLST movement began in Oregon in the early 1990s and is quickly gaining ground. Currently, all but seven states and the District of Columbia have a POLST program in place or are actively working to develop one. (To find out where your state stands and obtain program specifics, visit www.polst.org/programs-in-your-state/. Note that some states are using a different acronym, like MOLST – for medical orders for life-sustaining treatment.) The goal is reduce the use of costly end-of-life care – like ventilation – that patients overwhelmingly say they don’t want.
The POLST paperwork is filled out and signed by a physician, making it an actionable medical order (some states allow a nurse practitioner to authorize it). Unlike a vaguely worded advance directive, it spells out specific treatment instructions. It is usually printed on colored paper or otherwise designed to be highly visible and recognizable, whether it is kept at the front of the patient record or on the refrigerator door, where first responders may easily find it. The POLST form travels with the patient from one care setting to another. Some states, like Oregon, have created a statewide registry of POLST forms to provide secure, electronic access to orders if the paper copy cannot be found.
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