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| Advance Care Planning is a Patient’s Right |
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Patricia A. Bomba, MD, MACP, FRCP
Advance care planning (ACP) has garnered attention with the COVID-19 pandemic and the value has been demonstrated time and again with outcomes that truly matter – honoring the wishes of patients for treatment at the end of their life and helping families and loved ones cope with grief. Unfortunately, I know personally how difficult grieving is during the pandemic.
As someone who has experienced loss at a very early age, I recognized the need for high quality care for patients, support for families and effective communication skills for physicians and other clinicians decades ago. My beliefs were validated by my experience as a practicing geriatrician caring for patients with advanced illness and advanced frailty for more than two decades in their homes, my office, long term care settings, emergency room, general medical-surgical floors and intensive care units. I didn’t worry about care transitions, as I knew and cared for the patient and their family in all care settings. Over the past twenty years, I am privileged to work closely with physicians, NPs, PAs and other clinicians across New York and the country who agree that ACP is right. In NY, they collaborate with me as I lead NY’s MOLST and eMOLST programs on behalf of Excellus BlueCross BlueShield in a public-private partnership with the NY State Department of Health. I am a founding member of National POLST.
Initially, it was hard for me to read opinions of those who fail to see value in ACP. Upon further reflection, it isn’t difficult to understand given the variation in state laws, levels of patient and practitioner protections, different forms, and importantly, the evolution and variations of care in our current health care “system”. In addition, advance directives (ADs) like living wills do NOT work, as ADs cannot be followed in an emergency, patients often lack capacity when they present with acute illness, AND end-stage terminal illness often co-exists with a potentially reversible illness (e.g. end-stage dementia and aspiration pneumonia.)
The National Academies of Science, Engineering and Medicine Roundtable on Quality Care for People with Serious Illness recently hosted a virtual public workshop on the challenges and opportunities on ACP. The workshop offered a platform to acknowledge and highlight divergent viewpoints on this important topic.
The workshop opened with personal stories that framed the discussion. Speakers discussed what is empirically known and not known about ACP and its outcomes. The workshop identified areas where additional data and research is needed to fill gaps on the available evidence. In addition, the workshop aimed to identify potential approaches to improve the practice of ACP. The workshop was held over two webinars on October 26, 2020 and November 2, 2020. A recorded video and meeting materials is posted here.
I was honored to be among the presenters and briefly share NY’s population health approach to ACP developed in Rochester NY 20 years ago. The approach aligns with the 2017 Delphi definition and clarifies the differences between ADs and medical orders in two ACP programs: 1) Community Conversations on Compassionate Care for all adults 18 and older and 2) MOLST for all patients of all ages with serious illness who may die in the next year and briefly describe and share eMOLST data for the approximately 50,000 live patients in the registry.
After the NASEM workshop, a key article was posted on the New England Journal of Medicine Catalyst on Tuesday November 3: Rapid Implementation of eMOLST Order Completion and Electronic Registry to Facilitate Advance Care Planning: MOLST Documentation Using Telehealth in the Covid-19 Pandemic. The article addresses the rapid implementation of eMOLST at Mount Sinai Health System during the COVID-19 crisis last spring. The rapid implementation with the accelerated use of telemedicine complements the steady increased eMOLST implementation and experience in NY over the past decade.
While ACP is complex, it is right. We need to measure “what matters most” to patients and families.
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| Featured Resource: Rapid eMOLST Implementation to Facilitate Advance Care Planning During COVID-19 Pandemic |
| FAQ: Can eMOLST Integrate with EMRs and HIEs?
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Yes! Several integration options are available.
Single-Sign On (SSO): allows eMOLST user to log into eMOLST automatically when their login credentials are passed to eMOLST from an authorized source.
Single Sign-On with Patient Context: allows SSO plus automates the search for a patient during the login process by sending information on the patient inside the special message.
Application Programming Interface (API): allows a trusted system to query eMOLST for relevant information on a specific patient or to see if a patient matching those details even exists in the eMOLST registry. More granular information such as order status can also be delivered.
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| eMOLST Champion: Beth Popp, MD, FACP, FAAHPM, HMDC |
Dr. Beth Popp is a Palliative Medicine physician in the Brookdale Department of Geriatrics and Palliative Medicine at the Mount Sinai School of Medicine and Mount Sinai Health System (MSHS) in NYC. Dr. Popp trained in Internal Medicine, Medical Oncology and Hospice and Palliative Medicine. She is board certified in Hospice and Palliative Medicine as well as being a Certified Hospice Medical Director. She has more than twenty years of clinical practice experience.
She is currently holds the rank of Associate Professor, and is an experienced Clinician-Educator specializing in Palliative Care who has a demonstrated history of palliative care program development working in several hospitals and health systems in NYC throughout her career.
Dr. Popp is a driving force in eMOLST implementation at MSHS since she arrived three years ago. She is well known throughout the system for her clinical, teaching and team building skills. Given her statewide leadership positions, Dr. Popp recognized the value of MOLST for appropriate patients. With her extensive prior experience using eMOLST at Maimonides Medical Center in Brooklyn, Dr. Popp recognized eMOLST represents best practice.
When COVID-19 began, she realized eMOLST was the best tool to meet the needs of patients and families and advocated for accelerated eMOLST implementation.
She is the senior author in an article recently published online in the New England Journal of Medicine Catalyst which is this month’s Featured Resource: “Rapid Implementation of eMOLST Order Completion and Electronic Registry to Facilitate Advance Care Planning: MOLST Documentation Using Telehealth in the Covid-19 Pandemic.” The article outlines the experience and lessons learned at MSHS during COVID.
In addition to Dr. Popp’s clinical and teaching responsibilities at Mount Sinai, she serves as the chair of the NY State Palliative Care Education and Training Council and is a member of NY’s MOLST Statewide Implementation Team and the Team’s Executive Committee. She will be co-chairing the Team’s newly formed eMOLST Committee with Katie Orem, MPH, eMOLST administrator.
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| The Value of Our Family’s Thanksgiving Tradition During COVID |
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Patricia A. Bomba, MD, MACP, FRCP
Our family has a unique Thanksgiving tradition that dates to 1992 and has nothing to do with food or football. It’s our annual family advance care planning discussion when we share our personal values, beliefs and what makes life worth living currently in our lives. We share who we trust to make medical decisions, if we lose the capacity to do so. We started this tradition on Thanksgiving because it’s an American holiday that just about everyone celebrates, attracting family members from far and wide. While at first you might think it’s morbid to discuss such issues at a festive gathering, we’ve found having these discussions brings us closer and we have experienced the positive impact of having had these conversations when loved ones face the end of life.
Social distancing has brought some nuclear families together and separated others during the pandemic. With the rising number of COVID cases in New York, new restrictions are in place. Currently, but subject to change, gatherings at private residences will be limited to 10 people. As the holidays approach, families are considering new holiday traditions, virtual celebrations, outdoor gatherings. Similarly, our family is exploring options, including how to retain our family tradition, because we recognize our annual tradition is especially relevant now.
The value of advance care planning discussions, particularly for those with advanced illness and advanced frailty, has been demonstrated during COVID-19 crisis. The deterioration of health status and the ability to make medical decisions declined rapidly in many cases. Unfortunately, many patients delayed needed treatments, while others postponed important screening procedures. Hospital visitation restrictions during the COVID wave often contributed to confusion, delirium and suffering for patients admitted with COVID and non-COVID acute illnesses alike. The impact on families, loved ones and the medical team caring for them has been well described.
I encourage every family to embrace our Thanksgiving tradition during these challenging times. In our family, “No pumpkin pie, until you tell me how you want to live until you die.” In normal times, after the dinner dishes are cleared, the adults in our family stay at the table and talk about what matters most in our lives. We review how to make medical decisions using shared medical decision making and make sure everyone understands what matters most to each of us. This year we will do our discussions virtually.
Through the power of technology, these important advance care planning conversations can occur through phone and videoconferencing during this crisis, even when families cannot gather in the same place. Special considerations about witnessing the completion of a health care proxy during social distancing is described and a fillable PDF of the New York Health Care Proxy form is available on a dedicated COVID-19 Advance Care Planning web page on CompassionAndSupport.org.
Conversations change lives! Start your conversation today! What better time to start a conversation than at Thanksgiving during these challenging times when your family gathers in unique new ways for the holidays.
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