Understanding What Patients Want
In July of 2014, Oregon Health & Science University (OHSU) launched an effort called “Caring Wisely” that focuses on incorporating palliative care principles and practices into the standard care. Erik Fromme, MD, Medical Director for OHSU’s Palliative Care Service, and Ellen Distefano, MN, Quality Specialist, lead this mission and have worked to incorporate palliative care throughout a patient’s journey – not just in the final stages of an illness. This work echoes the American Academy of Hospice and Palliative Medicine’s Choosing Wisely® recommendation against delaying palliative care.
“In our organization, palliative care has become increasingly viewed as the responsibility of the palliative care team. Caring Wisely recognizes that all health professionals have the opportunity to incorporate palliative care into their practice, even if they don’t call it that. It’s the only way that we can ensure palliative care is available to all the patients who need it, not just those who are dying,” Dr. Fromme said. “It’s not one person’s job in the organization – this touches many hospital departments and many care team members.”
OHSU has multiple projects underway, three of which encourage patients and families to have important conversations about preferences and help them create advance care plans well before end-of-life decisions need to be made. One project targets advance directives (ADs).
“One of our oncology clinics looked at how many patients had an AD in their electronic medical record (EMR),” Distefano said. “It was 12 percent, but we discovered when we surveyed these patients that over 40 percent of them reported having completed an AD. We needed to fill this gap in to better know and honor patient preferences.”
Three months ago, a staff performance improvement meeting about ways to increase ADs in the EMR sparked an idea to routinely check for an AD and ask patients to bring a copy of an existing AD when they are seen in a clinic or admitted to the hospital. Staff then developed standard work to support consistent AD inquiry and scanning into the EMR. This project is in early implementation and has already seen an increase in the number of ADs in the EMR.
In addition, OHSU has pioneered use of the brightly colored “Physician Orders for Life-Sustaining Treatment” (POLST) forms to document medical orders for life-sustaining treatment consistent with the wishes of patients with advanced disease. Since these paper forms can be misplaced easily, OHSU worked with a technology company to create an electronic POLST (ePOLST) system that is embedded into the patient’s EMR. This system also ensures that the POLST form is automatically loaded into the Oregon POLST Registry, making it available to emergency personnel.
Finally, OHSU has worked to improve resuscitation conversations between physicians and patients with advanced disease, better known as “code status” conversations. As a framework for this communication, clinicians use a mnemonic device — SPAM — to ask patients about:
- Surrogates (if the patient has a person they trust to make medical decisions for them);
- Preference (if the patient knows what life-sustaining treatment they want if they are unable to make medical decisions);
- Assume (to let patients know that if they do not specify otherwise, staff will provide full treatment); and
- More (to let patients know the discussion will be documented in the EMR and staff will follow up, especially if their condition changes).
Staff noted that it is important to leave the door open for future conversations.
“Choosing Wisely helps disseminate evidence-based recommendations that improve care and reduce unnecessary tests and procedures,” Dr. Fromme said. “Caring Wisely focuses on fostering good decisions when the evidence is not conclusive by encouraging health professionals to understand and respect what is most important to patients and their families.”