Compassion and Support
APRIL 2016
New National Survey Reports on Barriers to Advance Care Planning Discussions

A national survey found most physicians feel that discussing advance care planning with patients is important, but many are unsure of how to broach the subject and start the discussion. The survey, released on April 14, is timely with the growing interest in advance care planning, in part related to the new CPT codes for advance care planning and MOLST discussions.

The survey was conducted by telephone from February 18 to March 7, 2016. The survey included 470 internists or other primary care clinicians, 85 oncologists, 87 pulmonologists, and 94 cardiologists. Physicians were asked their opinion of the new CMS decision to reimburse clinicians for conversations about advance care planning, along with questions about motivations, barriers and billing practices. All of the surveyed physicians saw Medicare patients and 74% said that they cared for patients who were likely to die within a year, a key screening question to identify persons appropriate for MOLST.

Of the physicians surveyed, 99% considered it important that clinicians discuss advance care planning with patients; 95% said they supported the new Medicare benefit; and 75% saying that the benefit made them more likely to have such conversations. In addition, 75% of respondents said they thought it was their responsibility to initiate advance care discussions.

Only 29% of the physicians surveyed reported formal training in end-of-life discussions with patients and families. Those who had formal training were more likely to report that end-of-life conversations were rewarding rather than challenging.

Key barriers included a lack of time (66%), a sense of disagreement between the patient and family members (64%), uncertainty about the right time to start a conversation (60%), and unsure of what to say during such conversations (46%.) In addition, physicians indicated that they did not want patients to feel that an advance care planning discussion meant that their physician was giving up on them (48%) or that they should give up hope (46%).

Physicians reported that their main motivations for starting advance care discussions were honoring their patients’ values and wishes (92%), decreasing unnecessary or unwanted hospitalizations toward the end of life (87%), and increasing patients’ and families’ satisfaction with care (81%).

Results of the nationwide survey, commissioned by the John A. Hartford Foundation, the California Health Foundation, and the Cambia Health Foundation, were released on April 14. A press release and other materials are available online.

Featured Resource: Survey on Dying in America Report

To assess progress since the release of the Dying in America report in September 2014, and to inform the work of a new Roundtable on Quality of Care for People with Serious Illness, the National Academy of Medicine is conducting a nationwide survey to track improvements over the past 18 months, discover barriers that have prevented progress, and better understand current areas of need. Please share your feedback and complete the survey.

MOLST FAQ: How Does A09859/S6314 Change the MOLST Process?

A09859/S6314 authorizes nurse practitioners (NPs) to execute orders not to resuscitate and orders relating to life sustaining treatments. It does more than permit an NP to sign a MOLST form. It provides the attending NP the same authority as the attending physician, including giving them the ability to determine capacity and address clinical standards. If this bill is passed, the attending NP who signs the MOLST form will be accountable for the set of medical orders created as a result of thoughtful discussions of values, beliefs, goals for care and shared, informed, medical decision making.

eMOLST Champion:
Greg Smalter

Greg Smalter is the lead developer for the eMOLST system. He has worked intensively on eMOLST development since 2012 and is a critical member of the eMOLST team. His honest, trustworthy, and straightforward approach to development and his focus on responding to user feedback have been integral to eMOLST’s growth. Greg has become a strong advocate for both MOLST and eMOLST through his work. He sees the benefits to patients and families in guaranteeing accessibility to critical eMOLST orders while recognizing eMOLST’s value in simplifying providers’ workflow regarding end-of-life discussions and documentation.

Several clinicians and eMOLST users have responded positively to Greg’s involvement in the eMOLST project, including Dr. Diane Kane, the Chief Medical Officer for St. Ann’s Community in Rochester. In a recent meeting Dr. Kane expressed her gratitude over several of the major improvements that Greg spearheaded in eMOLST development during 2015. She said,

“it’s exciting to work with the eMOLST team because they’re able to be responsive to our needs. Greg listens to the challenges we are facing and is willing to think creatively to develop solutions that will work both here and in nursing facilities across NYS.”

Greg is the Director of Development at Bross Group. He is an experienced software engineer and an active member of the .NET developer community. He specializes in the deployment of enterprise software systems, and in developing data-centric web applications with a focus on maintainability. He is responsible for the architecture and development strategy at Bross Group, where he is also personally involved in all healthcare-related software projects. He earned a BS in Software Engineering from the Rochester Institute of Technology , and is also co-creator of the Enterprise Web Library.

Bill Introduced to Authorize Nurse Practitioners to Execute NY MOLST

By Patricia A. Bomba, MD, FACP
VP & Medical Director, Geriatrics, Excellus BlueCross BlueShield

The NYS Senate introduced S6314 (A09859 in the NYS Assembly) that authorizes nurse practitioners (NPs) to execute orders not to resuscitate and orders relating to life sustaining treatments. S6314 was referred to Health on 1/6/16. A09859 was referred to Higher Education on 4/18/16. The legislation impacts NY’s MOLST and eMOLST programs.

MOLST is the only alternate form to the non-hospital DNR form approved by the Commissioner of Health, after 3 years of testing in the 2 pilot counties. Also, it is the only form that EMS can follow both DNR and DNI orders. This bill includes NPs as part of the MOLST process and authority to execute MOLST orders. In reviewing the legislation, there are key issues to consider.

The legal requirements for EOL decision making are set forth in the 4 key public health laws: Health Care Proxy law, MOLST, FHCDA, SCPA 1750-b. The requirements do not align with the realities of the current manpower and are not consistently followed. Manpower issues exist in hospitals, nursing homes, assisted living facilities, home-based palliative care programs, physician office settings, in particular but not limited to rural settings.

Quality gaps are identified as we work with systems to transition from paper MOLST to eMOLST. For example, some nursing home physicians ask social workers (SWs) to complete a MOLST that they sign without participating in the discussion. Directing SWs to get medical orders is clearly outside their scope of practice. MOLST forms with incompatible medical orders (e.g. CPR and DNI) pose a quality and patient safety issue. Other issues are outlined in an article published in the NYSBA Health Law Journal and by MLMIC.

We have well-trained physicians and NPs who lead teams that ensure quality MOLST discussions. Unfortunately, we know there is a gap in clinician training. The new national survey reports 68% of responding physicians said they never had training in those conversations. The result is variation in knowledge and skills of attending physicians. The same holds true for NPs, based the feedback from our NP colleagues, as well as SWs and other health care professionals.

I support the legislation but recommend consideration of certification of the NPs to ensure knowledge and skills. The same recommendation is made for physicians, based on recent survey data, as well as other clinicians. Key recommendations to overcome the quality gaps are clinician training, public engagement, education & empowerment and eMOLST implementation. These recommendations align with the 2014 Dying in America report.

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