Nov/December 2014
Doctors MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY
Advance Care Planning
it’s about the conversation In This Issue:
• Honoring Choices Minnesota—Past, Present, Future • POLST vs Advance Care Directive—What’s the Difference? • Luminary of Twin Cities Medicine
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CONTENTS VOLUME 16, NO. 6
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NOVEMBER/DECEMBER 2014
IN THIS ISSUE
Honoring Choices — It’s About the Conversation By Peter J. Dehnel, M.D.
4
PRESIDENT’S MESSAGE:
Difficult Decisions By Lisa R. Mattson, M.D.
5
TCMS IN ACTION
By Sue Schettle, CEO
6 Page 32
ADVANCE CARE PLANNING
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Honoring Choices Minnesota: An Initiative of the Twin Cities Medical Society
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Colleague Interview: A Conversation with Kenneth N. Kephart, M.D.
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Dying With Dignity: An Interview With Victor Sandler, M.D. By Karen Peterson, BSN
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What is POLST By Teresa Knoedler, JD
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Honoring Choices and HealthPartners: Partnering Inside and Out to Make a Difference By Mary Brainerd, and Brian Rank, M.D.
Page 27
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Honoring Choices Minnesota Data Outcomes: Participative Evaluation By Barbara Greene, MPH
21
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Supporting Late Life Care With Honoring Choices By Eric Anderson, M.D., and Sandy Schellinger, ANP
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Honoring Choices Minnesota/Advance Care Planning/Health Care Directive... It’s not what you call it, it’s about having the conversation with our patients By Dave Thorson, M.D., Angie Bentley, LPN, and Eileen Weber, DNP, JD, PHN, BSN, RN
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“We’ve Got This Idea” UMN Center for Bioethics and Honoring Choices Minnesota Form an ACP Mini-Academy Partnership By Barbara Greene, MPH
Page 27
27
MMA Annual Conference Held
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Address the Sleeping Giant: Effective Prediabetes Management for Physicians
29
Student Engagement
30
In Memoriam/ New Members Ebola Forum
31
Career Opportunities
32
LUMINARY OF TWIN CITIES MEDICINE
Kent Shannon Wilson, M.D.
Page 29 MetroDoctors
The Journal of the Twin Cities Medical Society
On the Cover: The Twin Cities health care community has embraced advance care planning and is promoting it to their patients and families. Read how this is being accomplished. Articles begin on page 6.
November/December 2014
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Doctors MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY
Physician Co-editor Peter J. Dehnel, M.D. Physician Co-editor Robert R. Neal, Jr., M.D. Physician Co-editor Marvin S. Segal, M.D. Physician Co-editor Richard R. Sturgeon, M.D. Physician Co-editor Charles G. Terzian, M.D. Medical Student Co-editor Katherine Weir Managing Editor Nancy K. Bauer TCMS CEO Sue A. Schettle Production Manager Sheila A. Hatcher Advertising Representative Betsy Pierre Cover Design by Andrea Farina MetroDoctors (ISSN 1526-4262) is published bi-monthly by the Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. Periodical postage paid at St. Paul, Minnesota. Postmaster: Send address changes to MetroDoctors, Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. To promote its objectives and services, the Twin Cities Medical Society prints information in MetroDoctors regarding activities and interests of the society. Responsibility is not assumed for opinions expressed or implied in signed articles, and because of the freedom given to contributors, opinions may not necessarily reflect the official position of TCMS. Send letters and other materials for consideration to MetroDoctors, Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. E-mail: nbauer@metrodoctors.com.
November/December Index to Advertisers
TCMS Officers
President: Lisa R. Mattson, M.D. President-elect: Kenneth N. Kephart, M.D. Secretary: Carolyn McClain, M.D. Treasurer: Matthew Hunt, M.D. Past President: Edwin N. Bogonko, M.D. TCMS Executive Staff
Sue A. Schettle, Chief Executive Officer (612) 362-3799 sschettle@metrodoctors.com Nancy K. Bauer, Associate Director, and Managing Editor, MetroDoctors (612) 623-2893 nbauer@metrodoctors.com Andrea Farina, Communications and IT Coordinator (612) 623-2885 afarina@metrodoctors.com Barbara Greene, MPH, Community Engagement Director, Honoring Choices Minnesota (612) 623-2899 bgreene@metrodoctors.com Karen Peterson, BSN Director of Program Operations, Honoring Choices Minnesota (612) 362-3704 kpeterson@metrodoctors.com
Allina Health.......................................................31 Coldwell Banker Burnet..................................12 Crutchfield Dermatology.................................. 2 Fairview Health Services .................................31 Federal Bureau of Prisons .................................... Inside Back Cover Greenwald Wealth Management ..................10 HCMC ................................. Inside Front Cover Healthcare Billing Resources, Inc. ...............15 Lakeview Clinic .................................................31 Lockridge Grindal Nauen P.L.L.P. ................. 7 Minnesota Epilepsy Group, PA ...................... 7 PrairieCare ...........................................................20 Saint Therese.......................................................13 Senior LinkAge Line......... Inside Front Cover Uptown Dermatology & SkinSpa................20
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For advertising rates and space reservations, contact: Betsy Pierre 2318 Eastwood Circle Monticello, MN 55362 phone: (763) 295-5420 fax: (763) 295-2550 e-mail: betsy@pierreproductions.com MetroDoctors reserves the right to reject any article or advertising copy not in accordance with editorial policy. Advertisements published in MetroDoctors do not imply endorsement or sponsorship by TCMS. Non-members may subscribe to MetroDoctors at a cost of $15 per year or $3 per issue, if extra copies are available. For subscription information, contact Andrea Farina at (612) 623-2885.
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November/December 2014
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The Journal of the Twin Cities Medical Society
IN THIS ISSUE...
Honoring Choices — It’s About the Conversation
H
onoring Choices Minnesota — the subject of this issue of MetroDoctors — is an initiative that is flourishing far beyond the original vision of the Twin Cities Medical Society. It has truly been a “game changer” in terms of expanding the needed conversations about choices concerning care at the end of life. From its humble beginnings in 2008, it has become a national model to assist clinicians, health systems and communities to more consistently have those important discussions before critical decisions have to be made. This issue of MetroDoctors contains important perspectives from a broad segment of the health care community. It also conveys the experience of implementing the principles into practice in a variety of settings. Ken Kephart, M.D., current Medical Director for Honoring Choices, provides the input for our “Colleague Interview.” As an early corporate champion of Honoring Choices, Mary Brainerd, CEO of HealthPartners teams up with Brian Rank, M.D., Executive Medical Director, to give HealthPartners’ experience with the ability to integrate the program into their normal clinic processes. Victor Sandler, M.D., Medical Director of Fairview’s Home Care and Hospice Program, relates in the article “Death with Dignity” how Honoring Choices has been a significant force behind improving the overall advance care planning climate in Minnesota. “Supporting Late Life Care with Honoring Choices” co-authored by Eric Anderson, M.D. and Sandy Schellinger, describes Allina’s development of their “LifeCourse” program and how that has greatly improved patient-centered conversations about end-of-life decisions. Dave Thorson, M.D., Angie Bentley, LPN and Eileen Weber, DNP, JD discuss the experience of Entira Clinics in using Honoring Choices to mobilize their clinics to facilitate conversations around end-of-life planning. Additional information is provided by Teresa Knoedler, JD, Policy Counsel for the MMA, who explains By Peter J. Dehnel, M.D. Member, MetroDoctors Editorial Board MetroDoctors
The Journal of the Twin Cities Medical Society
“POLST” — Provider Orders for Life Sustaining Treatment. Barbara Greene, director of Community Engagement for Honoring Choices, gives important outcome information about the Honoring Choices program. Lisa Mattson, M.D., President of TCMS, penned “Difficult Decisions” describing her very personal experience with end-of-life situations. Kent Wilson, M.D. is the true “physician champion” behind Honoring Choices and is very appropriately the subject of this month’s “Luminary.” Where are you with end-of-life discussions? How does your clinic or practice setting approach end-of-life conversations? At what age do you start the conversations? If your patient is 72 years old, has end-stage kidney disease secondary to diabetes, congestive heart failure and COPD, the decision to have a conversation may be easy. How does that help the family of the 22-year-old son who has a devastating motorcycle injury with no hope of recovery? How about the husband of the 32-year-old woman who has an unsuspected intracranial AVM rupture during the delivery of their third child? What does it do for the spouse or adult children of the 54-year-old man who has a severe head injury in a remote mountain region and cannot be extracted from the site until long after his intracranial pressure has caused irreparable damage? One “out of the box” thought: the best application of Honoring Choices may be to eventually extend the conversation to all adults. The goal would be to ensure that all people have their end-of-life intentions known long before anything irreversible ever happens. While many things in life are generally predictable and expected, the importance of this topic is too great to leave to chance — for anyone. We hope that you enjoy this edition of MetroDoctors.
November/December 2014
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President’s Message
Difficult Decisions LISA R. MATTSON, M.D.
MY MOM LOST HER BATTLE WITH CANCER AT THE AGE OF 36. It was the 1970s and her original round of chemotherapy had been hard on her. When the cancer metastasized to her lungs she declined anymore chemo; she argued that for every day it would keep her alive, she’d spend that day being sick. It was about the quality of the days she had left. She was able to go to a Tupperware party the day before she died, and she ultimately died peacefully in her own bed. Fast-forward 16 years: I’m a resident rotating through the ICU. I have a patient with terminal cancer whose long, lost daughter has come back into her life and wasn’t ready to let her mom go. The daughter had transferred her mom to our hospital for a second opinion and declared her a full code. We didn’t have anything more to offer and we almost lost her a few times but the daughter was always there insisting that we give her pressors to bring her blood pressure up. My patient was ready to end her fight and knew she was never going to be able to leave the hospital on her own, but she needed her daughter to be ready to say goodbye. My experience was not unique. Most of us in health care have experienced similar situations, and some extreme cases have found their way into the local and national media. No one really wants to think about the end of his or her life. We all hope we die peacefully in our sleep and without any pain. Yet none of us know what tomorrow will bring. How many of us have thought about what we want in the event of unwanted illness or significant bodily harm, let alone talk about it with our families? I’ve often wondered how things would have been different for my patient if she’d had better communication and quality time with her daughter before her cancer had progressed. Honoring Choices is all about communication among family members before a life-threatening situation arises. Creating opportunities for people to share their wishes obviates the need for loved ones to make difficult decisions during times that can already be filled with emotional turmoil and helps minimize guilt for spouses and children. It isn’t about “death panels” and withholding lifesaving treatments. It’s about encouraging people to discuss various medical scenarios and the possible treatment options. The choices can be different depending on the situation. One person may want every life-saving measure at the age of 55 when going in for a routine orthopedic procedure but choose minimal intervention in the event of a traumatic brain injury or after a long battle with a terminal illness. I was just a kid when my mom made her decision to not do anymore chemo, but her choice always made sense to me. We had a summer with her and she had some closure with family. She didn’t die in a hospital or a nursing home, and aside from needing oxygen, she was able to take care of herself. I have always been grateful that she didn’t suffer a prolonged and drawn out illness. Her ability to express her desires ultimately made a difficult time a little easier for my family. We may not be able to control every aspect of our life, but knowing which choices have been made in advance of our death may make dying easier for ourselves and our loved ones. It has been my pleasure serving as your President this past year. I look forward to the continued leadership of your Executive Committee, incoming president Ken Kephart, M.D., Sue Schettle, CEO and the TCMS staff. 4
November/December 2014
MetroDoctors
The Journal of the Twin Cities Medical Society
TCMS IN ACTION SUE A. SCHETTLE, CEO
Legislative Visits TCMS member, Stuart Cox, M.D., hosted a meet and greet for Senator Susan Kent (DFL-Woodbury) at the Midwest ENT/St. Paul Eye Surgery Center in Woodbury on Monday, August 11.
On Monday, September 8, Lisa Mattson, M.D., TCMS president and Pete Dehnel, M.D., chair of the TCMS legislative and policy committee, hosted Majority Leader, Representative Erin Murphy (DFL) at Boynton Health Services/University of Minnesota.
President-elect of TCMS, Ken Kephart, M.D., met with Senator Melissa Franzen (DFL) on Thursday, August 27 to discuss Honoring Choices Minnesota and the impact that the initiative is making in Minnesota. Lisa Mattson, M.D., president of TCMS, testified at the St. Paul City Council in August as they contemplated MetroDoctors
strengthening their ordinances relating to e-cigarettes. TCMS member Peter Bornstein, M.D. hosted Representative Matt Dean (R-38B) at a restaurant in North Oaks on Friday, September 26, 2014. Attendees included: Peter Bornstein, M.D., Matt Kruse, M.D., Rep. Dean, Sue Schettle, Pete Dehnel, M.D., Lisa Mattson, M.D., Evelyn Clark, and Bob Geist, M.D.
E-Cigarette and Other Flavored Tobacco Products Toolkit and Spokesperson Training TCMS received a grant from the American Lung Association to support the creation of a physician and medical student toolkit. The toolkit will be created to educate members about the facts on e-cigarettes and other flavored tobacco products. We will also be holding four educational sessions for interested members throughout the remainder of 2014 and into 2015 with the goal of having our members better informed on: 1) local and state policy issues; 2) latest scientific information; and 3) opposition. Honoring Choices Minnesota Our expansion beyond Minnesota just keeps growing. The two newest states to sign onto the Honoring Choices family of states are Honoring Choices Virginia and Honoring Choices North Dakota. Both states join Florida, Massachusetts, Wisconsin and Napa Valley — so, we can honestly say we are a nationwide initiative. TCMS receives an annual royalty fee for use of the name Honoring Choices and in some cases consultation services.
The Journal of the Twin Cities Medical Society
Journal of Geriatrics We are excited to announce that the Honoring Choices story will appear in the December 2014 issue of the Journal of Geriatrics. This is the first time that TCMS has had anything published in a peer reviewed journal. Thanks to Dr. Kent Wilson and Dr. Tom Kottke for coauthoring the article with me and for their patience as we worked our way through this 18-month process. MN Cancer Alliance Work Group I have agreed to serve as chair of the MN Cancer Alliance’s Work Group on Advance Care Planning. The goal of the work group is to understand who is doing what in advance care planning, what data is being collected, and what opportunities exist to coalesce and report the information in a meaningful way. The MN Cancer Alliance is a broad partnership of organizations and leaders from across Minnesota, all of whom are dedicated to reducing the burden of cancer across the continuum from prevention and detection to treatment, survivorship and end-of-life care. Foundations As I write this the path is clearer to me than it has been in the past that the East Metro and West Metro Foundations will indeed be merged effective January 1, 2015. The feedback that we have received from members has been all positive, especially given the fact that we are making a concerted effort to preserve the legacy of both Foundations as we move to one organization. November/December 2014
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Advance Care Planning
Honoring Choices Minnesota
An Initiative of the Twin Cities Medical Society
H
onoring Choices Minnesota (HCM) is a collaborative, community-based initiative led by the Twin Cities Medical Society through its East Metro Society Foundation. TCMS serves as the convener and coordinator, utilizing its unique access to health care organizations and medical professionals. Beginning in the Twin Cities metropolitan area and spreading across the state and country, HCM’s goal is to spur conversations about future health care preferences and to assist health care
decisions. The result of these conversations is usually a Health Care Directive. HCM promotes the importance of these ongoing conversations.
organizations and community partners with the installation of a comprehensive advance care planning program. HCM uses the training, principles and overall methodology of Respecting Choices, the nationally and internationally recognized model based out of Gundersen Health System in La Crosse, WI. This effort has grown into a movement and is a truly remarkable example of how health care and non-health care organizations can work together to provide better medical care for Minnesotans. Advance care planning is not merely the completion of a Health Care Directive or Living Will. Instead, it is a thoughtful process, ideally utilizing a certified advance care planning Facilitator, trained to engage patients in discussions about their desires and values for future health care treatment
munity members wholeheartedly agreed that there was a need, and senior leadership gave their unanimous support to: 1. Not compete; 2. Provide resources to support an initiative; and 3. Advocate internally within their respective organizations and advance the initiative. An advisory committee was then formed to set the framework for the community collaborative. In 2009, a name and logo were selected, patient education materials were ordered from Gundersen Health, and educational events began. A new Minnesota-specific Health Care Directive was developed by the advisory committee and is available online at no charge in five languages. The advisory committee also began collaborating with
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Background
In 2008, TCMS convened two exploratory meetings — one with community members and the second with senior leaders of hospital systems and health plans. Both meetings were held to gauge interest in collaborating and coordinating resources related to advance care planning. Com-
related groups and efforts such as the Institute for Clinical Systems Improvement (ICSI), MN POLST (Provider Orders for Life Sustaining Treatment) workgroup, and National Healthcare Decisions Day. Health Care Organizations Pilot Honoring Choices Minnesota
Organizational commitment to HCM was obtained from a number of Twin Cities health care systems in 2009, with Mary Brainerd, CEO of HealthPartners, agreeing to serve as the Corporate Champion. Fifty health care leaders attended a twoday training course and were equipped with tools and resources to prepare their organizations for launching pilot sites. Organizations chose patient population(s) for piloting the program and identified individuals to be trained as advance care planning Facilitators and as Instructors. (Facilitators lead advance care planning discussions with patients and their families. Instructors serve as in-house experts who train new Facilitators and help guide organizational advance care planning efforts.) Workflows were defined and discussions occurred regarding the process of referrals to Facilitators and which quality measures to collect. There were seven pilot sites operating during 2010. In July, 2010, the first Sharing the Experience Conference allowed all sites to convene and report on their findings. Following additional training, five new pilots began in 2011. In 2012 and 2013, additional pilots began, including the first non-health care site — a financial services organization offering advance care planning as an employee benefit. Sharing the Experience has become an annual
MetroDoctors
The Journal of the Twin Cities Medical Society
conference, bringing partners and pilots together every July to learn from one another’s experiences. Growth
HCM is widely accepted throughout the health care community and continues to provide training and resources. In fact, other states are adopting our name, resources and structure. Patient education materials have been developed jointly with several local health care systems and are being used widely. Additional organizations continue to come forward with interest in pursuing this model within their systems. Our collaborative work is supported partially through the medical society and East Metro Medical Society Foundation, as well as through funders who have enabled a more substantial effort and allowed public engagement to move ahead. Partnerships now exist beyond the traditional health care community and include ethnic, cultural and religious representatives, social services organizations, senior services groups, foundations and other organizations. Our guiding hope is for all Minnesotans to understand the importance of advance care planning and be familiar with Honoring Choices Minnesota as a resource. Community Engagement
HCM partnered with Twin Cities Public Television (TPT) to create a collection of seven documentaries and over 700 online video clips designed to help Minnesota families have conversations about endof-life care and advance care planning. Viewers are empowered to begin advance care planning and use resources to guide family conversations. A joint project established with the Minnesota Council of Churches brings advance care planning into faith communities around the state. The HCM Ambassador Program has trained more than 50 physicians, nurses, chaplains, social workers, community leaders, multicultural representatives and other volunteers to spread the message within diverse communities through public speaking in seminars, conferences and other educational events. MetroDoctors
The Journal of the Twin Cities Medical Society
November/December 2014
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Advance Care Planning
Colleague Interview: A Conversation with Kenneth N. Kephart, M.D.
K
enneth N. Kephart, M.D. serves as the Medical Director of Honoring Choices Minnesota. He is the Medical Director for Senior Services at Fairview and Adjunct Professor for the Department of Family Medicine at the University of Minnesota. Dr. Kephart received his medical degree from the University of Minnesota Medical School and completed his family practice residency at St. Paul-Ramsey Medical Center, St. Paul, MN. He is Board Certified in Family Practice with a Certificate of Added Qualification in Geriatrics. He is also a Certified Medical Director and a Diplomat of the American Board of Hospice and Palliative Medicine.
What is the estimate of the overall percentage of Minnesota seniors who have executed Advance Health Care Directives by the time of death?
To what degree has the above percentage increased as a result of programs such as Honoring/Respecting Choices — i.e. a measure of program effectiveness?
This is a good question, and there is not one answer. We do have some unprecedented preliminary results for our state that have not been reported before, coming mainly from the CDC’s “BRFSS” (Behavioral Risk Factor Surveillance System) survey. The CDC’s BRFSS survey has standardized questions administered in all 50 states that compare behavioral trends over time. Minnesota is the only state that has been successful in including Advance Care Plan (ACP) questions to the survey thanks in large part to the acknowledgement of DHS and MDH (where the survey is administered) of the impact of ACP in Minnesota. Data from first quarter this year showed 66 percent of those surveyed had knowledge about Health Care Directives. 35 percent reported completing one, which rises to 51 percent for those over 65. Most common reason for not completing directive was: Haven’t gotten around to it at 53 percent. While 90 percent said they have asked someone to speak for them, studies have shown most do not or those proxies don’t know they have been selected and/ or do not feel they know patient’s wishes well enough to carry them out. Another significant indicator comes from Minnesota Community Measurement’s reporting of a pilot study conducted 6/2013-11/2013. In that study of eight medical groups representing 56,000 patients age 65 and older, report 32 percent as having an ACP in the medical record of their health care home clinic.
Respecting Choices in La Crosse clearly has set a high bar. They have been working in their community for over 20 years and their last reported measures at time of a patient’s death was approximately 95 percent of patients had an ACP in their records and it was followed 99 percent of the time. Currently we don’t have good composite numbers for HCM. Individual systems have done some measurements at time of death and have reported doubling of ACP in records from when they started 5-7 years ago from a baseline of about 20 percent to over 40 percent.
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What is the usual reaction (e.g. relief, resignation, etc.) of typical individuals after completing a Living Will or Advance Care Directive? The typical reaction is positive. Patients tell us they feel good about taking care of these decisions and letting their family know of their wishes. If the conversation occurs outside of and in advance of a medical crisis there is no data that suggests this discussion is disturbing to a patient or robs them of hope. Families are especially relieved following the discussion. It is far easier to carry out a loved one’s wishes as opposed to making end-of-life decisions for someone and feeling responsible for it. Our job is to make sure their wishes are known and honored when the time comes. MetroDoctors
The Journal of the Twin Cities Medical Society
Advance Care Directives ultimately are only effective if health care clinicians are aware of their presence and follow those directives. How effective are our clinicians in fulfilling these end-of-life care responsibilities? We are getting better. Systems have increasingly made the ACP easy to find within their EHR and physicians are starting to look for and use this information. We have a long way to go however. It takes time to change culture and the culture of a physician deciding on treatment without asking about ACP is still too prevalent. We will know we have truly changed the culture within our systems when a sentinel event is called and a physician has to explain their decisions to a group of peers when a clear and available ACP was not followed.
Are there specific tools that help or barriers that hinder following the directives? Current barriers are that there is no standardized way ACP is viewed in EHRs and there is no reliable registry patients or physicians can rely upon.
What has been the financial implication to the TCMS Foundation from their role in this program? Positive, HCM has raised contributions from large health systems, health plans and foundations that have covered all the costs of our work plus help with some overhead cost that benefits the TCMS.
Where did the expense land for the Twin Cities Public Television program? This was money raised by contributions made primarily by health systems and health plans specifically for HCM. No dues money from members was used.
Have there been any, and if so what, unintended/ unexpected positive and/or negative consequences with program roll out? Positive consequences have been the strong positive response from the community, especially the faith communities wanting to be a part of this effort. Many religions feel they have a responsibility to help members of their faith make decisions about their care as they approach death. TCMS has also developed a positive relationship with The Conversation Project, an IHI led initiative whose mission is closely aligned with HCM. I hope we can collaborate with other programs in the future. I cannot think of a major negative consequence with program roll out. There have been failures or lack of progress for individual systems but this is expected in a program of this type.
Is there collaboration/cooperation among competitive organizations? Please provide specific shared operational expertise and/or other resources. Yes. TCMS only started this program after a meeting in the fall of 2008 where CEOs of the major health systems and health plans were asked if they would collaborate and specifically not compete if TCMS facilitated this program. Since then we have set up an advisory or steering committee comprised of representatives from the major health systems and health plans to help guide us. We meet regularly and freely share best practices among members. We also try to make decisions by consensus. One of our goals is to use the same forms and facilitation training across the health systems and in the community. In this way we can help make basic ACP a community activity primarily done outside our clinics. This will allow us inside the health care system to focus our resources on the chronically ill and patients approaching death. Many of our patients get their care from multiple systems, primary care in one but specialty care in another. Common forms and processes are helpful in those patients. We also have an annual “Sharing the Experience� conference where presenters from different systems share their best practices and stories.
Has there been any notable change in metro Emergency Departments regarding POLST or Advance Care Directives? Yes, I believe so. EMS and ERs are starting to look for and follow POLST in an emergency. Since this is the only question mentioning POLST I will take a minute to explain what it is. POLST is the outcome or result of advance care planning put in an outpatient order format. It is meant to be used, especially in an emergency in the outpatient setting and as a guide to ER physicians if a patient cannot be asked their wishes due to their condition. Section A and B regarding code status and intubation wishes are especially helpful. It is primarily used for patients living in nursing homes or assisted living facilities, homecare and hospice or anyone expected to be in their last few years of life. It is not a legal Advance Directive. Of note, EMS and ER personnel rarely have time to look for or use an advance directive or comprehensive plan.
Is the Advance Care Planning documentation included in EPIC Everywhere medical record data set? Is it available to other care givers in some other vehicle? Yes, but it is not located or viewed in the same place in each EPIC EMR. Currently each system’s version of EPIC handles this information differently. TCMS and the Minnesota EPIC User Group have been meeting with EPIC to work on an ACP (Continued on page 10)
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The Journal of the Twin Cities Medical Society
November/December 2014
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Advance Care Planning Colleague Interview (Continued from page 9)
How can we “normalize” the inclusion of this topic in everyday practice?
module in their next upgrade so it would be viewed the same way across different EPIC users. There are also several on-line national companies that are signing up patients to upload their medical information including Advance Care Plans with the promise of making them available to care givers when needed. There has also been some preliminary talk of looking at some kind of state registry that would be available to care givers when needed.
What, specifically, can physicians do to increase the use of advance care directives for patients of all ages? They can ask about and recommend advance care planning as a routine part of their practice at selected visits. Studies of smoking, diabetes and exercise have shown that physician recommendations can significantly influence patients to modify behavior or take action. We then must provide them with an efficient process to order ACP facilitation, much like they might order diabetic education for their diabetic patient. Lastly we must measure the outcome of these activities and establish benchmarks for practices. Physicians tend to do what is measured. Physician leaders must make ACP a part of the quality measures of a practice like diabetes care.
Normalizing this for medical practices is outlined above. Our goal in HCM as a community health initiative is to help normalize this topic for our community. To do this we must bring the discussion outside of the walls of our practices and into places of worship, community centers and volunteer organizations. We will know we have accomplished our goal when families have the conversation regarding their end-of-life wishes at their kitchen table and let us know of their wishes. We then have a hardwired process for storing that information, regularly reviewing it and being able to find it and honor it as they approach death.
And why should they be motivated to do so, especially if their scope of practice is well removed from end-of-life care? Mainly because it is the right thing to do, not only for their patients but also for themselves and their families.
As medical director, what is your vision for Honoring Choices Minnesota and ACP in the years ahead? Continue working with our community and health care partners until we have truly normalized advance care planning for all in our community.
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November/December 2014
MetroDoctors
The Journal of the Twin Cities Medical Society
Dying With Dignity An Interview With Victor Sandler, M.D. Death With Dignity
Just what do those words mean? Some say dignity is an inherent quality an individual possesses — not something a physician can offer through care. Others say respectful treatment of a patient enhances and supports dignity, and as such the care given can make end of life more dignified. Dr. Victor Sandler is the Medical Director of Fairview Home Care and Hospice, co-chair of the University of MN Medical Center’s Bioethics Committee, president of MN Network of Hospice and Palliative Medicine Physicians, and cochair of the Minnesota Medical Association’s POLST initiative. Dr. Sandler was in the first cohort of physicians certified in the specialty of hospice and palliative medicine in 2008. He credits his relationship with his grandmother for steering him from internal medicine to geriatrics and eventually to hospice and palliative medicine. “I don’t have any medical stories to share about my relationship with my grandmother, but I developed a real appreciation for older people because of the relationship I had with her.” He also cites the writings of Elisabeth Kübler-Ross, who edited a book entitled “Death, the final stage of growth,” and Rabbi Abraham Joshua Heschel, whose essay on piety reinforces the image of life as a gift, as influential in his life. In his mind, death with dignity is patient-centered and brought about when the patient’s wishes, values, and choices are known and respected by all involved — the health care team as well as family and friends. “Death with dignity has to be seen By Karen Peterson, BSN MetroDoctors
through the eyes of the person whose death it is we are talking about. For most people, it means dying at home, and of course that means being surrounded by the people they love — family and friends.” Dr. Sandler explains that for this to happen, the care of a hospice team is invaluable, providing medical, nursing, emotional, and spiritual support. Unfortunately, Dr. Sandler relates, the use of hospice and palliative medicine is not as widespread as it should be. Around 70 percent of all people die in hospitals or nursing homes,1 which we know from surveys is not what the majority of people want.2 Our medical system is geared toward aggressive treatment, and doctors talk about and recommend aggressive treatments because it’s what they are trained to do. Clearly modern medicine has made great strides in treatment options, but “we have to look at the other side,” Dr. Sandler explains, “for elderly and frail elderly patients, aggressive care is not what they usually want, and we, as doctors, can only know that by talking openly with them.” He stated that a study conducted by the journal Cancer3 indicated doctors have a strong tendency to avoid discussion of prognosis, code status, and hospice options for patients with a terminal diagnosis. “It’s very simple, really. Patients have to understand their prognosis in order to make informed decisions about the kind of care they want, including code status. And they have to know what hospice and palliative medicine is so they can choose what’s right for them.” Dr. Sandler distinguishes that hospice care is one form of palliative care delivered to patients who are terminally ill, using the Medicare criteria of an
The Journal of the Twin Cities Medical Society
Dr. Victor Sandler photo by Dan Olson / Minnesota Public Radio. (c) 2011 Minnesota Public Radio. Used with permission. All rights reserved.
anticipated life expectancy of less than six months to define “terminal illness.” With elderly and frail patients, he emphasizes how important it is for doctors to give all the information about treatment options, including the option of no active disease treatment — which would incorporate palliative care. Physicians must also inform patients that they have a greater likelihood of complications following a treatment if they are older and frail. He warned against the “technological imperative” where doctors fall into believing that because we can do something we should. It’s recognized that many patients respect their physicians and have the perspective that if their doctor talks about a treatment option, they should accept it — why would it be brought up if it weren’t a good option for their situation? The reverse can also be true. Occasionally a patient or family may request interventions that the physician believes are not indicated. When (Continued on page 12)
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Advance Care Planning Dying With Dignity (Continued from page 11)
there is a potential divergence between patient autonomy and non-maleficence, an ethical dilemma is posed. The physician’s responsibility is to weigh the benefits and burdens of the various treatment (and non-treatment ) options and recommend to the patient/family what he/she believes to be in the best interest of the patient. “In my experience as a bioethics consultant, geriatrician, and hospice and palliative medicine physician,” Dr. Sandler reports, “disagreements are avoided by effective communication, education along with tincture of time. Patients and families make good decisions the vast majority of the time if they are communicated with in a respectful manner and allotted appropriate time for questions. When this does not occur ethics consultation should be considered.” Dr. Sandler advises doctors need to keep these warnings in mind, recognize situations where the patient is really much more likely to benefit from palliative
A test of a people is how it behaves toward the old. It is easy to love children. Even tyrants and dictators make a point of being fond of children. But the affection and care for the old, the incurable, the helpless are the true gold mines of a culture. Abraham Joshua Heschel medicine, and communicate effectively to ensure all involved can reach agreement. “Hospice is often the best care these patients can receive — nationally on average, they live longer if they receive hospice and/ or palliative care, plus the quality of their life is improved. We’re doing a disservice to patients by not talking about this alternative proactively.” Education is Key
Dr. Sandler is one of only 6,5004 certified hospice and palliative medicine specialists in the country. He believes that number needs to be significantly larger; fortunately there are growing fellowship programs around the country in hospice and palliative medicine, including at the University
of Minnesota. Sadly, in the critical and complementary field of Geriatric Medicine the University of Minnesota is way behind the curve. Dr. Sandler finds it frustrating that there is not more leadership from the School of Medicine at the University of Minnesota. “At this time, there is no division of geriatric medicine there. There is no Geriatric Medicine fellowship. I believe there are only two or three geriatricians at the med school currently, in family medicine. Right now in four years of medical school there’s only two days of education devoted to geriatric medicine, end-of-life care, palliative medicine and hospice — and that’s totally inadequate.” He continues, explaining, “The University of Minnesota is a land grant university,
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and as such has a service responsibility to the residents of our state. I believe it is defaulting on that responsibility by not providing more emphasis on geriatrics and end-of-life care in undergraduate studies, and by not supporting the needs of the older citizens.” Minnesota currently has about 750,000 residents over the age of 65, but that number will double within 30 years5 — precisely when today’s medical students will be practicing. “Medical students today are able to take electives in hospice and palliative medicine, so we are making some progress, but it’s been an uphill struggle. We really need to make dramatic strides forward in this area.”
My patients taught me not how to die, but how to live. Elisabeth Kübler-Ross Dr. Sandler cites Honoring Choices Minnesota as being a significant force behind improving the overall advance care planning climate in Minnesota. To ensure doctors support patients’ end-of-life desires to die with dignity, “we have to normalize the conversation about death, and bring in advance care planning early. Incorporating advance care planning into primary care is important and, thanks to the participation of most Minnesota health systems working with Honoring Choices, we’ve come a long way. Only doctors know the medical prognosis for these patients [with chronic illnesses] and it’s incumbent upon them to say ‘you know, you’ve got some serious issues and we need to talk about what is going to come in the years ahead.’” Only when doctors begin conversations like these can they be sure they clearly understand what their patients really want. And only when they know what their patients want can doctors respect those wishes, and allow for the final period of life to unfold with dignity. Dr. Sandler shared a recent experience, visiting a hospice patient who is in his final days. This man has an aggressive form of cancer which has metastasized and he chose, after understanding all of his options and the possible outcomes and MetroDoctors
complications, to forego chemotherapy. He is now living at home, being cared for by his adult children, with the ongoing support of the hospice team. On this day, Dr. Sandler had been called in to evaluate a distended abdomen, to determine if paracentesis was a recommended treatment option. As it turned out, the distension was related to metastases in his liver, and therefore not amenable to paracentesis. As they chatted, the patient had tears in his eyes, but not, Dr. Sandler is quick to explain, because he was dying. Rather, they were tears of gratitude. This man was at peace with his diagnosis, knew he had lived a good life, and knew he had raised good children who were now supporting and caring for him and spending their final time together with him in his home. “This was my small piece to contribute to this man’s life. This man is living out life with a terminal condition, but is at home, surrounded by loved ones, not in a hospital surrounded by machines. This, to me, is the type of death I would want
The Journal of the Twin Cities Medical Society
for any member of my own family, and for all of our hospice patients.” This is a man who is dying with dignity. Karen Peterson, BSN, Director of Program Operations, Honoring Choices Minnesota, working to support health care systems in the development and expansion of Advance Care Planning programs. She interviewed Dr. Sandler in September, 2014, for this article. Footnotes: 1. http://www.cdc.gov/ nchs/data/dvs/Mortfinal2005_worktable_309.pdf Centers for Disease Control [2005] NCHS Data. 2. http://www.ncbi.nlm.nih.gov/pmc/articles/ PMC1059324/ Journal of Medical Ethics: J Med Ethics. Sep 1983; 9(3): 158–161. 3. http://www.medscape.com/viewarticle/715471 Medscape Medical News. 4. http://aahpm.org/hpm/number-certified American Academy of Hospice and Palliative Medicine. 5. http://www.mncompass.org/demographics/ age#1-5229-g Minnesota Compass: Minnesota State Demographic Center and U.S. Census Bureau, Decennial Census and Population Estimates.
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What is POLST?
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e are fortunate to be living and dying in a community that supports and values endof-life planning. It may not be possible for every single person to die with dignity, but we move closer to that aspiration every day. One of the tools that help people to die with maximum self-determination and dignity is POLST. POLST stands for Provider Orders for Life Sustaining Treatment. Like an Advance Directive, it is an end-of-life planning tool. Unlike an Advance Directive, a POLST form is not appropriate for every adult. Rather, POLST should be used for people who are very ill, near death, or who have a chronic medical condition that gives them a reasonable understanding of how they are likely to die. It has been said that POLST is appropriate if a patient is likely to die within one year. Increasingly, POLST is also being used in patients whose medical condition may not be imminently terminal, but whose medical condition has some highly probable eventual outcomes, such as with degenerative neurological conditions. A POLST form is the embodiment of detailed conversations about end-oflife likelihoods and treatment preferences that take place between a patient, their loved ones, and (ideally) multiple providers. A POLST form is a medical order from a physician or other provider that outlines the patient’s wishes regarding endof-life care. It is intended to accompany the patient across treatment settings and home care, so that other providers are able
By Teresa Knoedler, JD
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to discern a patient’s end-of-life wishes quickly and with precision. Where Did POLST Come From?
POLST as a concept began in the mid1990s at the Center for Ethics in Health Care at Oregon Health and Science University. Advance Directives were being used broadly, and had been embraced by patients, providers, health facilities, and government institutions. This increased use fleshed out some of the limits of an Advance Directive, particularly for that subsection of patients whose medical condition provided a strong understanding of how they were likely to die, and correspondingly strong opinions about their treatment preferences. Advance Directives were often not being followed by emergency responders. The broad conceptual desires expressed in an Advance Directive often did not give enough detail to a provider treating a critically ill or dying patient. Patients found that their Advance Directives were not as “portable” as they had hoped, and found themselves compelled to engage in redundant conversations with multiple providers. It became clear that some patients who wanted to give meaningful input on their end-of-life treatment required a more explicit and potent tool. Providers who worked with end-of-life patients wanted to be able to provide orders that would help effectuate their patient’s known wishes. Something stronger than an Advance Directive was needed. After years of exploration and pilot projects, the Center for Ethics in Health Care developed the POLST paradigm. POLST was created to ensure a patient’s
end-of-life wishes are communicated across care settings and providers, and are honored as closely as possible. The POLST concept took off to varying degrees across several states. Most states have a POLST program; Oregon’s POLST program is the most robust, and includes a state-wide POLST registry. For many years, Minnesota used a standardized DNR/DNI form to address basic end-of-life wishes. During that time, a few hospital systems used a version of POLST internally. After weathering several challenges to the POLST concept, Minnesota’s long-term care and hospice communities came together in the mid-2000s, along with Emergency Medical Service providers and Minnesota physicians, to develop a state-wide POLST program. How is it Being Used in Minnesota?
The standardized Minnesota POLST form was endorsed by the Minnesota Medical Association and the Emergency Medical Services Regulatory Board in 2009. Since then, there have been a number of small changes to the form. There has not yet been any legislative action regarding
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POLST, which has perhaps caused POLST to be lesser-known than Advance Directives (which are codified in Minnesota Statute). The adoption of POLST across Minnesota has been organic and demanddriven. Many long-term care and hospice facilities use POLST for every patient who desires a POLST. In some areas, penetration is low, perhaps due to lack of education on the part of patients or providers. There is no central registry or other mechanism of keeping track of POLST use and outcomes. Anecdotally, it is clear to providers in the long-term care and hospice communities that POLST is increasingly being used as an advance planning tool, and that patients value the opportunity to concretely determine end-of-life care. The POLST form recently replaced the DNR/DNI form on the Emergency Medical Services Regulatory Board website, and EMS training is ongoing. Based on the growth and dissemination of POLST in other states, it was understood that POLST usage would be incremental and meandering. The MMA remains the host for the Minnesota POLST Work Group. The Work Group is beginning a utilization and outcome assessment survey and will use the data gathered to direct further outreach and educational efforts.
Advance Directive, and carries the weight of a provider order. A POLST form, completed with the help of a provider, addresses the specifics of end-of-life care. POLST reflects decisions made about specific treatment options a patient does or does not want, relating to care that is most likely imminent or ongoing. A POLST form is a medical order signed by a provider, and is designed to provide guidance to first responders. Like an Advance Directive, a POLST form can be changed or revoked at any time. It should reflect a patient’s most current wishes about her death. A POLST form must be reviewed upon patient transfer, or if a patient’s medical condition has changed, or if a patient expresses a desire to revisit the POLST form. When appropriate, a patient may have both a valid Advance Directive and a valid POLST form. The two need not be contradictory, and can provide complementary information about the totality of a patient’s end-of-life wishes. A patient may have a long-standing Advance Directive, and
may elect to use a POLST form at the onset of a terminal illness. Conversely, a patient may have an Advance Directive, and may never develop the need for a POLST form, because of a sudden death. Also, a patient who had not previously engaged in advance care planning, due to lack of knowledge or fear, may decide to use a POLST form when diagnosed with a condition that renders the circumstances of the patient’s death predictable. There are many different ways the two advance planning tools can be used together and separately to ensure selfdetermination, dignity, and control at the end of life. Most importantly, both forms arise from and should reflect ongoing, contemporaneous conversations with providers about end-of-life treatment preferences. Teresa Knoedler, JD received her law degree from the University of Minnesota Law School and currently serves as Policy Counsel, Minnesota Medical Association. She can be reached at (612) 362-3738 or tknoedler@ mnmed.org.
How Does POLST Fit With Advance Care Directives?
POLST and Advance Directives are different instruments that share a common goal: patient self-determination and dignity at end of life. Advance Directives are more general documents. They are signed by a patient and represent a patient’s best guess at their end-of-life preferences, in the abstract. Usually, a patient drafting an Advance Directive does not have specific knowledge about end-of-life decisions; rather, an Advance Directive reflects the patient’s wishes at a conceptual level. Advance Directives are designed to address future care needs, and are not designed to provide substantive guidance to first responders. Every person should have an Advance Directive, starting at age 18. POLST is more specific than an
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Honoring Choices and HealthPartners: Partnering Inside and Out to Make a Difference
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s we were preparing to write this piece, Brian remembered a story. It was years ago, during his residency. He was called to answer a code. It involved a quarter-mile sprint to the bedside of an unconscious man whose body had been made fragile by advanced prostate cancer. To live, the man needed immediate CPR. With no guidance available from the man to direct otherwise, Brian began the procedure, which succeeded. But it caused harm, too — breaking many weakened ribs of a man who, inevitably, would soon die. Would resuscitation have been the man’s choice in this case, given the harm? What would his family have wanted? No one would ever know, as the man had no Advance Care Directive in place and couldn’t speak for himself. Society has made good progress on advance care planning since then. But these scenes remain far too common, playing out in our hospitals every day. For many doctors, even our newest colleagues, similar stories are easy to bring to mind. Moments like these are desperately hard on everyone involved — especially patients and their families. Doctors are obligated to save life, but sometimes they must act knowing that treatment harms more than helps, and without knowing the most important thing — what the patient wants. Advance care planning is our best ally for ensuring the best possible end-of-life
By Mary Brainerd, and Brian Rank, M.D.
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experiences for patients and families. But the conversations are difficult to have and easy to avoid. It’s long been an area calling for fresh, innovative approaches and partnerships. Helping to Build a New Community Commitment
This is why, in 2008, HealthPartners readily accepted the invitation of the Twin Cities Medical Society and Dr. Kent Wilson to contribute to exploratory work around what would eventually become Honoring Choices Minnesota. We were glad to have a seat at the table and to work alongside other organizations already doing foundational work in this area, including Park Nicollet, with which HealthPartners would later combine. The Twin Cities medical community
is no stranger to the idea of collaboration for the good of the community. In the Institute for Clinical Systems Improvement (ICSI), for example, we’ve built and sustained a nationally recognized example of how care systems and health plans can set competition aside to bring about needed change and innovation. As the concept of Honoring Choices took shape, however, our group started to extend that tradition of medical collaboration into new territory. We realized that the idea of advance care planning is not — and cannot be — simply a matter of medicine. It has deep connections to other parts of our lives, from our family relationships, to our faith, our finances and more. It means different things to different people, and usually reflects influences
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of deep cultural traditions. It involves no “right answers.” So we asked: Where else could and should we take this grass-roots conversation, and who else should we invite? How can we build the best infrastructure and create the best, most meaningful access for everyone in our community? And we asked these questions in light of a simple but significant truth: Starting a conversation about death is hard. What could we do to make it easier? The answer, and what became the defining characteristic of the Honoring Choices approach, was to invite the whole community — to enable conversations not only in doctors’ offices but also with financial planners, faith leaders, community groups, the media and many others. As the general history of Honoring Choices is described elsewhere in this issue, we’d like to offer a perspective on our organization’s experience and thoughts for the initiative’s future. What Honoring Choices has Meant for HealthPartners
As an integrated provider of care and coverage, we know how important it is for families to have conversations about their health care preferences long before they are critically ill or become critically injured. Too often at our hospitals, we meet with families whose loved ones had never expressed their wishes nor written Advance Directives; families who never had advance care planning conversations. We see the very hard decisions these families must make and how it affects them — often taking a huge emotional toll. Our doctors and their teams are skilled in working with patients, but most wouldn’t claim a special advantage or innate ability to begin conversations about end-of-life issues. Imagine rooming nurses, for example, many of whom are early in their careers. Their daily work with patients presents natural opportunities to ask about directives. How do you make it easy for them to raise the importance of advance care planning with a patient in a confident, forthright way? MetroDoctors
For us, Honoring Choices has answered this need with resources that remove much of the guesswork, awkwardness and emotion from the process. It combines thoughtful interpersonal approaches with practical care processes — helping patients have discussions and then recording directives in the medical record. It then allows us to share information across our own systems, and between others, to honor choices no matter where patients seek care, 24/7. As we’ve said, this is a community effort. But we also view it as an organizationwide initiative, not the responsibility of a single HealthPartners department or team. Advance care planning is addressed in our long-range organizational goals and many of our departmental annual plans. We now have report card metrics that allow us to raise internal awareness and check our progress at our sites. In our care systems at HealthPartners, Park Nicollet, Lakeview and elsewhere, we now have many clinicians trained as facilitators who can lead individuals and families through advance care planning conversations. We’re also proud to have helped develop the “short form” of the Advance Directive that’s now available on the Honoring Choices website alongside the longer, more comprehensive form. This document had origins some years ago in a physician-led pilot project at a HealthPartners neighborhood clinic. The fact that it’s now being used metro-wide is another testimony to the welcome spirit of collaboration in Honoring Choices. Overall, Honoring Choices is making a difference at HealthPartners. Physicians tell us that patients and families are pleased that we’ve taken the time to encourage the conversation. Our emergency room department doctors and others are finding more and more directives in electronic medical records. And we’ve seen that the conversations we’ve had with patients are so much more effective because they’re joining and echoing conversations happening elsewhere in our community.
The Journal of the Twin Cities Medical Society
Honoring Choices Across Our Region and Beyond
If asked to grade the success of the Honoring Choices collaborative, we’d give it an “A.” In support of patient- and family-centered medicine, it respects conversations around advance care planning as something holy. It engages without preaching; it invites without dictating. It supports the role of doctors and care teams as servants of those who choose us for their care. And it’s another example of a Minnesota initiative that models something that can and should be spread nationally. All of this is thanks to the great, dedicated work of Kent Wilson, M.D., Sue Schettle and Barbara Greene of Honoring Choices, Bill Hanley at Twin Cities Public Television, our partners at the EMMS Foundation and TCMS, and all of the partnering organizations. They all deserve tremendous gratitude, continued support and a share in our community pride. Our message, however, must be “so far, so good.” We still have much work to do. The opportunities to broaden and deepen the work of Honoring Choices are many and compelling. In particular, we see opportunities to employ more virtual and web-based tools, technologies that offer more portability, and more customization for specific cultures and smaller populations. We also want to encourage an even broader community profile for this work such that the touch points become so commonplace as to be unavoidable. One of the best and most gratifying indicators of our success will be to hear more and more patients say, when asked about a directive, “Oh, I’ve already taken care of that.” As doctors and care teams, working in partnership with our community, we’re serving as both a prompt and checkpoint to make that happen. Throughout our organization, it will continue to be our honor to do so. Mary Brainerd is President and CEO at HealthPartners. Brian Rank, M.D., is an oncologist and Executive Medical Director at HealthPartners. They can be reached at (952) 883-6000. November/December 2014
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Honoring Choices Minnesota Data Outcomes: Participative Evaluation There is no such thing as a failed experiment, only experiments with unexpected outcomes. – Richard Buckminster Fuller, U.S. engineer and architect, 1895-1983 One of the most frequently asked questions that Honoring Choices Minnesota (HCM) hears is, “So tell me — what are your outcomes?” Since the initiative first began, the challenge of capturing accurate outcome data has been daunting. How do we begin to capture meaningful measures that may not be fully visible for several decades? How can we document the story of Minnesota’s advance care planning roots and its growth throughout other states? This article gives all stakeholders a broader perspective of our organic impact — both close up and at a panoramic distance. Beginning in 2011, HCM started data collection with our partnering health systems and broader community organizations. We initiated a contract with Rainbow Research in 2012 to help us navigate our growth from both a 200-foot perspective and a 20,000 foot high observation deck. With more than 40 years of active community-based evaluation experience, Rainbow Research carefully took an inventory of qualitative and quantitative data collected. They strongly suggested that the initiative use a participative evaluation model with measurements from many audiences and participating organizations. According to Rainbow Research consultant Ann Zukoski, DrPH, “Participatory research is an alternative to the traditional mold of conventional linear research. It focuses on actively engaging stakeholders in the evaluation process — to identify relevant questions, plan the design, select appropriate measures, and gather/interpret the data. This kind of research takes a “bottoms up” approach by including participants in the planning and implementation. Our goal is to work with populations, not on them to capture meaningful outcomes.” Based on this model, the following results reflect what we’ve learned so far about our multi-faceted efforts. Our tools include tracking sheets, telephone interviews, web-based analytics, patient records from partnering health care systems, and more. One thing we know is that this process is evolving. Here’s where we stand today.
Health System Data
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• •
•
1,700 trained First Step™Advance Care Planning Facilitators in 8 Minnesota partnering systems (Allina, Entira, Fairview, HealthEast, HealthPartners, North Memorial, Park Nicollet, Ridgeview) and multiple community organizations 60+ trained First Step™Advance Care Planning Instructors in Minnesota 8 hospital systems partnering with Honoring Choices report 12.1 percent to 65.5 percent of inpatients have Advance Directives in their EMR; Furthermore, the 8 systems also report that 11.6 percent to 31.7 percent of their total patient population (inpatient and outpatient) have documented plans in their EMR1
1) April 2013 survey of hospital systems partnering with Honoring Choices Minnesota.
Community-Centered Data (since 2011)
• • • • • • •
60 community Ambassadors trained — 20 consistent active champions >350 community, faith2, multicultural, and other presentations (through August 2014) >30 professional local, state, regional and national conference presentations 56,500 total website visits to www.honoringchoices. org 17,180 Health Care Directive hits (to forms in English, Somali, Hmong, Spanish, and Russian) >40,440 total visits to HCM documentary, video stories, and the resources web page >20 total media stories in newspapers, journals, radio, television and other sources
2) 2013-2014 ACP partnership between the Twin Cities Medical Society and the Minnesota Council of Churches.
By Barbara Greene, MPH
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Infrastructure Outcomes State Data
•
MDH/Minnesota Community Measurement Advance Care Planning Pilot Summary (July 2013-September 2013)3 • 8 medical groups; 68 clinics and 56,764 patients over age of 65 • Average rate of advance care planning completion was 32.1 percent • Performance ranges by medical group 12 percent-97 percent
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CDC survey administered at the state level — Minnesota Behavioral Risk Factor Surveillance Survey4 (provisional data from telephone interviews with >15,000 Minnesotans from February-May 2014) • While 66 percent of Minnesotans interviewed indicated they have knowledge about Health Care Directives, only 35 percent indicated they have completed a directive; • Of those who indicated they have not completed a Health Care Directive, 53 percent cited the reason why as “they haven’t gotten around to it;” • Of those completing their Health Care Directive, 67 percent stated they gave it to their provider; 29 percent said they have not given it their provider; and 4 percent were not sure.
•
In all data collection steps, HCM has focused on qualitative and quantitative outcomes. In exploring broad systemic outcomes, feedback continues to show that: • ACP is recognized by both leadership and operating staff as a critical component of the end-of-life continuum of care; • ACP is identified as “value added” process that enhances patient health care experiences: • Health system ACP changes include standardized and improved ACP work flows, processes, and models; • Patient Health Care Directives (including the new “short form” and revised original form) are standardized aspects of patient care; • Better IT ACP metrics and reporting standards are becoming quality improvement efforts. • ACP patient education materials are more thoroughly used with patient populations; • Changes to electronic medical record (EMR) documentation are occurring for better tracking; and • Better ACP data collection measures are in place within the broader HCM collective and will be used in 2014 data collection. (Continued on page 20)
Health Effectiveness Data and Information Set (HEDIS)5 • 77.5 percent of adults 66+ have a documented Advance Care Plan in 2012 compared to 30.5 percent in 2009 (a variety of factors contribute to this change). Rates of documented Advance Care Plans differ greatly between health plans, ranging from 60 percent to 97 percent.
3) Minnesota Department of Health and Minnesota Community Measurement pilot summary report to MARC committee April 2014. 4) Minnesota Dept. of Health Behavioral Risk Factor Surveillance System (BRFSS) provisional data from telephone interview surveys of >15,000 Minnesotans over 18 years of age. 5) Minnesota Department of Health Healthcare Effectiveness Data and Information Sets Reports Home Page, September 2014.
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Advance care planning involves learning about the types of decisions that might need to be made if a person becomes sick or disabled, considering those decisions ahead of time, and then letting others know about the individual’s preferences, often by putting them into an advance directive (National Institute on Aging, National Institutes of Health).
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Advance Care Planning HCM Data Outcomes (Continued from page 19)
Looking Forward
In early 2015, HCM will celebrate the publication of its first major ACP medical journal article in the Journal of the American Geriatrics Society. We also look forward to have a highly improved health system measurement process to capture January 1-December 31, 2014 data. We are finding better ways to help us “share our story” in eight states (WI, MA, FL, Napa Valley CA, WA, OR, VA, and ND are active partners who access our documentaries, video clips, web materials, Health Care Directive, and other resources). In the years ahead, a core part of our focus will specifically look at better ways to measure our impact in reducing ACP health care disparities, increasing levels of ACP conversations within our multicultural populations, and “beginning the conversation” within interfaith congregations. These goals require an even greater understanding of how to measure changing perceptions toward end-of-life care. William Butler Yeats, one of Ireland’s greatest 20th century poets, concluded that “The world is full of magic things, patiently waiting for our senses to grow sharper.” If we can sharpen our skills to measure ACP innovations that lie ahead, we’ll have made a huge step in expanding the reach of this national conversation. Meanwhile, our collective experiences are building a clearer evaluation footprint. We know one thing for certain: the Honoring Choices health system and community experiment is slowly changing end-of-life care decision making and our culture of care. Barbara Greene, MPH, Director of Community Engagement, Honoring Choices Minnesota, Twin Cities Medical Society.
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Supporting Late Life Care With Honoring Choices
U
nderstanding the wishes and aspirations of our patients is no longer window dressing on the serious business of treating medical illness. It is increasingly recognized as the pivot point around which the success of our medical interventions turn. This article briefly describes Allina Health’s implementation of advanced care planning (ACP). It goes on to describe how we built upon the principles of ACP to offer supportive care to individuals with serious illness and their families. Our health system took up the challenge of advance care planning seven years ago. Like others, we instituted Honoring Choices Minnesota, based on the Gunderson model of Respecting Choices. This included basic advance care planning facilitation and developing a cadre of trained disease-specific ACP facilitators. Our clinics implemented basic ACP at the Welcome to Medicare visit, at pre-op physicals, and in followup visits after hospitalization. Our electronic health record did not adequately support ACP. Working with a group of providers, we redesigned the organization of ACP documentation. The new EHR now prominently displays code status, and it enters advance care planning as a permanent diagnosis on the patient’s problem list. Clicking on ACP in the problem list immediately brings up the key summary information about the patient’s proxy and wishes. By Eric Anderson, M.D., and Sandy Schellinger, ANP MetroDoctors
Finally, all of the supporting documentation — scanned Health Care Directives, powers of attorney for health care, and POLST forms — are pulled to a single, easily identified location. It appears on the home page of each visit, whether the chart is opened in the hospital, emergency department, or clinic. Our hospital partners, particularly social workers and hospitalists, stepped up to the plate, accepting the challenge to record their code status discussions in a consistent format in the medical record. This overview document lists a proxy, the proxy’s contact information, and preferences for treatment choices. It is included in the standard, readily available information mentioned above. The results? The number of individuals hospitalized with an Advance Care Plan on the chart doubled. A reliable mechanism was built into the discharge process to link patients to an ACP facilitator. Documentation of Advance Care Plans in discharge summaries of
The Journal of the Twin Cities Medical Society
patients served by hospitalists jumped from 5 percent to 84 percent within a year. And the number of days spent in the hospital in the last six months of life decreased, but only slightly. It became apparent that ACP was one piece of moving care decisions upstream, but only a piece. Experiences from our Palliative Care colleagues were helpful in two ways. First, hospice lengths of stay for patients in our community-based palliative care team were longer than for other patients. Second, a research project by Dr. Drew Gottfried and Laura Lathrop, DNP, found that better end-of-life outcomes occurred when the hospital palliative care team was engaged earlier in the trajectory of decline. These findings illustrated the value of intervening earlier, before a medical crisis. Finally, there is the human factor. Anyone who has dealt with serious illness (Continued on page 22)
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Advance Care Planning Supporting Late Life Care (Continued from page 21)
in a family member can relate to at least one of these experiences: trying to get answers in the middle of the night, helping an elderly relative stay in her home despite physical and cognitive changes, adjusting to a new care setting where the story of illness has to be repeated so that staff understand what to do, or even connecting with a trusted physician to make decisions when our patients are cared for by a series of attendings in a variety of venues. As physicians, we often step in to help family members negotiate the complexities of advanced illness. What about those not lucky enough to have a nurse or physician in the family? We were convinced that the principles of ACP — honest inquiry into what matters most — were a good foundation for late life supportive care. What if there was a model of care that would deliver the best of Minnesota’s medical services — hospice, home care, and hospital care — while providing support for non-medical concerns, and a personal connection with patient and family that endures over time and across venues of care? In 2012 Allina received a grant from the Robina Foundation to develop and test a late life supportive care model. Now in its third year, we have followed over 250 patients and their families. Input from patients and caregivers informed the model from the start. They even chose the name, “LifeCourse.” Rather than assuming what was needed, we started with personal experiences of care. This inquiry included hours of interviews with patients, caregivers, and community professionals with the help of Twin Cities Public Television. For those interested, clips of these interviews are available at the TPT website: www. lifecoursemn.org. The model for late life supportive care emerged in three “buckets.” No one bucket holds it all; they are different 22
November/December 2014
Ted is 99 and Thinking About the Future
Ted is nearing the age of one hundred. He states, with some humor, “I don’t want to live to be 100, but I lack conviction… As you can see, I’m still alive.” In their initial visit, Ted and his care guide identified some important end-of-life considerations that he had never thought about. Would his trusted internist have an opinion about the timing of hospice care? Had his cardiologist ever talked about deactivation of his implanted defibrillator? And would his pastor ever have counseled others faced with making faith-informed decisions about their medical care? For the care guide, her relationship with Ted provided the opening to portray these issues as normal discussions that anyone might have in his situation. Shortly after the first meeting, Ted had already met with his spiritual guide, and he was looking forward to a conversation with his internist.
ways of understanding the intervention. First, our patients and caregivers asked that we abide by some principles of relationship: Ask me, Hear me, Respect me, Support me, Guide me, Comfort me. All our caregiver experts related the experience of managing their loved one’s care. When we asked them to assign care team members to a baseball club, they cast themselves as the pitcher, and usually as the manager, too. One caregiver commented about their trusted primary physician, whom they liked very much. She was at the game — as a fan in the left field stands. We got the point. For the medical system to recognize and honor their captaincy of the ship was seen as terribly important. Second, we needed to commit to seeing the whole person. This meant understanding something about physical, emotional, spiritual, familial, social, cultural, legal, and ethical concerns that are part of people’s lives. And third, we studied the kinds of interventions that seemed most applicable to late life needs. Examples include storytelling, individualized care, and collaboration across systems and communities.
The final question was: Who should do this work? We already have care coordinator nurses following up after a hospital stay. Cancer clinics often assign a nurse guide to each patient. Many Allina clinics have care guides, lay persons who support patients trying to manage a chronic condition. What else was needed? The model needed to meet people where they were at, and the best place is in their homes. We elected to develop a specially trained care guide, a lay person with college education and good communication skills. The care guide is backed up by a team of clinicians, such as an RN, chaplain, pharmacist, or others. The LifeCourse care guides see patients at least monthly. They understand what matters most by hearing patients’ stories and attending to all aspects of human experience. They encourage patients to voice their needs, and they support patients’ relationships with their various medical and social caring teams. Now we can circle back to advance care planning. Certainly, it makes sense to normalize ACP and offer it early. The care guides are all trained to do this. At a deeper level, the hour-long
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disease-specific ACP sessions touch on personal values, preferences for decisionmaking and family relationships. The practice of capturing wishes and preferences in ACP is a respectful model for inquiring about the whole person. This kind of inquiry is woven into the process of a care guide’s work. Will this late life supportive care approach achieve its goals of a better care experience, better utilization of supportive medical services, and a better quality of life for patients, their families, and even the medical professionals providing their care? Our early results are both statistically significant and clinically encouraging. Patients report they feel increasingly listened to and respected as they participate in LifeCourse. Families report less anxiety as the months go by, and their quality of life improves overall. They feel increasingly supported, and they report the same on behalf of their loved ones. Finally, cost of care declines for those enrolled more than expected. The next step will be to compare these changes to the experience of control patients and families. You have the opportunity to look into the lives of a few of our LifeCourse
Dean Seeks to Avoid “God’s Waiting Room”
Dean collapsed from a heart attack a year ago, and now Bonnie helps him live with his chronic heart condition. At the start of the care guide’s visit, Bonnie and Dean made a number of transactional requests, for example, could the care guide drive them to appointments? Through open questions across a range of topics and interests, the care guide understood Dean’s resistance to the medicalization of his life, his desire to avoid a nursing home (“God’s waiting room”), and Bonnie’s increasing efforts to keep their lives on an even keel. The care guide learned about their children, and invited Bonnie to seek assistance from them for the first time. Even in this first visit, the care guide appreciated core aspects of Dean’s person that color all his interactions with health care. Finally, the care guide used the couple’s desire for independence to motivate them to apply for subsidized transportation, rather than offering to drive them himself.
patients. TPT, (Twin Cities Public Television), is producing a series about the late life experience. It is not focused on the research, but on the challenges and richness of this time in people’s lives. These documentaries can be found at www.lifecouresemn.org. Honoring Choices has encouraged all of us to begin the conversations about Advance Directives earlier, and to help us make them part of normal medical
Thera and the Tree — She’s Still in There
Thera, an elderly woman with dementia, lives at the nursing home. Sitting at the window, she commented frequently on a small tree outside. She watched as the groundskeeper planted it, then followed its growth over several years. Thera spoke of it as a small child, scrawny and frail, that gradually grew into a big, strong tree. This transformation brought her great joy. The care guide collected Thera’s statements over the months, and compiled them, along with a photo of the tree taken with her cell phone. The result was an illustrated poem that spoke deeply of the loving mother that Thera was, even in her final years. Members of her family were deeply touched to see their mother’s essence so clearly reflected. This openness to seeing individuals as fundamentally unitary is particular to the whole person care of LifeCourse.
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practice. They are a powerful element of supportive care. We hope that our experiment in expanding the scope of support will demonstrate new ways to improve the lives and care experience of those with serious illness. Eric Anderson, M.D., has been involved in end-of-life interdisciplinary care for nearly 30 years. He served as the medical director of Allina Hospice, and later helped develop Allina’s inpatient palliative care teams. Dr. Anderson serves as the Principal Investigator for the LifeCourse project, and he continues to see patients on the Palliative Care service at United Hospital. He can be reached at: Eric.Worden.Anderson@ allina.com (612) 262-1448. Sandy Schellinger, ANP, has nearly 30 years of nursing experience focusing on the care of patients and families with chronic progressive illness. She provides hospice and palliative care consults for Allina patients and families and is also a National Faculty Member and Instructor for Respecting Choices. Ms. Schellinger serves as the clinical co-investigator for the LifeCourse project. She can be reached at: Sandra. Schellinger@allina.com (612) 262-1444.
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Advance Care Planning
Honoring Choices Minnesota/ Advance Care Planning/Health Care Directive... it’s not what you call it, it’s about having the conversation with our patients “Who would speak for you if you couldn’t speak for yourself?” That is the question we are asking our patients at Entira Family Clinics. We care about our patients and want to have the conversation that is sometimes hard to think about. But it is so rewarding for all involved when patients’ values and wishes are known prior to something bad happening. When the time comes to make important end-of-life decisions, approximately 50 percent of people are physically or mentally incapable of participating in those decisions. Grieving families then struggle to make painful choices. If the Entira health care providers, as well as the acute care providers in hospitals and long term care, do not know the patient’s values and wishes, their default decision is usually to preserve biological life as long as possible. As we are learning from many of our patients, such a decision is often in contrast to preferences for a more natural, less painful death. Honoring Choices Minnesota offers a written Health Care Directive, a document used by Minnesota health care systems to guide us in advance care planning conversations with our patients. Those discussions with patients and families identify patients’ values and preferences, resulting in plans that clarify end-of-life care goals to guide treatment decisions. The choice isn’t between “doing everything” or not. By Dave Thorson, M.D., Angie Bentley, LPN, and Eileen Weber, DNP, JD, PHN, BSN, RN
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The choice is between doing everything to fight the pathiophysiology that is ending someone’s life and doing everything to maximize comfort, fulfillment for patient and family, and acceptance. Entira’s aim is to help our patients understand how important advance care planning is and to offer support in completing Health Care Directives. This is why our 12 physician-owned family medicine clinics have implemented a systemized process to accomplish this goal. As a provider-owned and operated system, we have the ability to initiate and implement projects at a clinic system level. Since all of our departments work closely together, we were able to meet and quickly come up with a plan for putting the Honoring Choices process in place, starting with discussions in 2012. Staff met to decide how this would work in our clinics. Who would have the necessary in-depth conversations with patients, preferably including families, how would those staff be trained in facilitating that conversation, and how would we promote the importance of this to our patients? We sent two health care home RNs and a project manager to the “Respecting Choices” training that was offered through the Twin Cities Medical Society. We then
discussed an implementation workflow and projected how it would affect all people involved in the process, including patients, their families, and all relevant clinic staff, from medical records to the providers seeing the patients for their office visits. From that point, we educated all of our staff by attending medical staff and clinic meetings to help them understand our process and to offer them a chance to add input and insight to how this would work in their day-to-day work. Learning early on that three trained staff was not nearly enough for the number of patients requesting this service, and considering the community focus of the original Respecting Choices program initiated by the Gundersen Health System in Lacrosse, WI, we decided to reach out to our patient population of those interested in volunteering their time to work with our patients. Two patients were approved, completed patient privacy forms consistent with HIPAA, and sent to the “Respecting Choices” training for advance care planning conversation facilitators. Then we explained the Entira process of how to securely get the names of patients interested in meeting with them, and how to get the completed documents into our electronic medical record system. Clinics could also make copies for patients so they could widely share their wishes with their health care agent, other providers, and loved ones. We meet with the volunteers once a month to discuss the process, make
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any recommended changes, and share deidentified facilitation experiences. We now have six staff and seven patient volunteers trained in facilitating the Honoring Choices conversation. They are available, free of charge, to meet with our patients and their families in completing Health Care Directives. Our goal is to have two patient volunteers available for this service at each of our 12 clinic sites. When we asked one of our patient volunteers about her experience with our Honoring Choices work at Entira, this is what she had to share:
she saw her deceased father go through: repeated futile resuscitations.” Typically, the details that are covered in the Honoring Choices Health Care Directive are: • naming a health care agent (this is someone trusted to speak on the patient’s behalf in a medical emergency); • goals, values and preferences about health care and quality of life are clarified; there is no “right” or “wrong” in advance care planning, as decisions and values are simply individual preferences for end-of-life care; and
Patients were unaware of the usual practice of having hospitalists writing orders and directing care. This emphasized the importance once again of having Advance Care Plans communicated and stressed in the EMR.
“My involvement has included facilitating the necessary conversations with patients and their family members sitting around the kitchen table and in clinic conference rooms. And, I have participated in Honoring Choices education sessions at Sloan Place. I have also enjoyed working with other health care professionals and health care students (physicians, nurses, social workers) to plan and lead the University of Minnesota’s workshop held last March, along with HCM staff, Barbara Greene. One of my more interesting conversations with someone completing a directive was a young woman with unstable housing and bipolar disease who started out wanting all measures taken at all times because she wanted caregivers to know she wasn’t suicidal anymore. After we discussed that, she ended up wanting to avoid what MetroDoctors
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medical treatment that is desired or declined, such as CPR, ventilators, and artificial nutrition/hydration. Those interested in learning more about this service offered by Entira Family Clinics, can ask any Entira provider or clinic staff. We provide a link to the Honoring Choices document on our website for patients to download and get further information: http://www.entirafamilyclinics.com/AboutUs/PatientForms.aspx. It is listed as Honoring Choices Health Care Directive. Other suggestions we give our patients for where to keep copies of the document are in the glove box of their car, in their luggage when traveling or going south for the winter, and on their refrigerator in their home for EMS (Emergency Medical System) providers to have access to their
The Journal of the Twin Cities Medical Society
wishes in case of an emergency. Unfortunately, EMS is not likely to follow the directive unless it is accompanied by Physician Orders for Life Sustaining Treatment (POLST; see related article on page 14). This is an important issue for providers and EMS first responders to address so that patients’ preferences for care are honored. We have also held three sets of Honoring Choices Education classes publicized and open to any of our patients — with the most recent one held in September, 2014. This is promoted through our Entira website and flyers hanging in our clinics. This class offers Honoring Choices basics, and we hand out education materials. It also gives the patients and their families the opportunity to ask questions of us (the facilitators and Entira staff ) and other patients share their learning’s as well. One fact many have found surprising is that when hospitalized, their Entira physician, while aware of their hospitalization, would not be managing their care while in the hospital. Patients were unaware of the usual practice of having hospitalists writing orders and directing care. This emphasized the importance once again of having Advance Care Plans communicated and stressed in the EMR. We are pleased with reaching our goal of implementing Honoring Choices at all 12 of our Entira health care home clinic sites. Consistent with the goals of patientcentered medical homes and the professional desire of our providers to serve each patient’s needs, Entira will continue to work toward our goal of having all of our patients select desired health care agents and preferred end-of-life care, expressed in a document for themselves, their providers, and their trusted loved ones. Co-written by: Dave Thorson, M.D. Entira Family Clinics, Family Practitioner and Medical Director of Physician Relations; Angie Bentley, LPN – Entira Family Clinics, Honoring Choices Project Manager; and Eileen Weber, DNP, JD, PHN, BSN, RN – Patient Volunteer Facilitator for Entira Family Clinics Honoring Choices Project. http://www.entirafamilyclinics.com.
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Advance Care Planning
“We’ve Got This Idea” UMN Center for Bioethics and Honoring Choices Minnesota Form an ACP Mini-Academy Partnership
H
ow can a community-based partnership with the UMN Center for Bioethics foster ACP education and dialogue? Last spring at the Minneapolis Mill City Innovation and Collaboration Center, 28 participants of diverse ages and backgrounds learned how to begin the ACP conversation. With UMN Center for Bioethics and School of Nursing professor Joan Liaschenko, Ph.D., RN. FAAN and Bioethics master’s degree student Terri Traudt, attendees shared a rich dialogue on “Health Care Directives: Beyond the Document to the Conversation.” The session explored the history of Health Care Directives and emphasized the value of having a deeper ACP conversation. Honoring Choices Minnesota leaders Ken Kephart, M.D. and Barbara Greene, MPH also described how health system and community-based facilitators can assist individuals and their loved ones. UMN Center for Bioethics Director and Associate Professor Deb DeBruin, Ph.D. shared the importance of bringing ACP into metro communities. “This Mini Bioethics Academy session on Advance Care Planning was an important addition to discussions we have hosted over past years. We believe the public is eager for dialogue on this timely subject. Having Honoring Choices Minnesota participate in the event significantly
Presenters (from left) Joan Liaschenko, Ph.D, RN and Terri Traudt, MA.
helped to stimulate important community decisions.” Center for Bioethics Professor Joan Liaschenko agrees. “It is a challenge to create opportunities for this kind of communication on end-of-life care. This session is a powerful way to change and normalize cultural-centered communications on what “living well” means. This collaboration provides the opportunity to integrate the conversation into everyday life.”
The Twin Cities Medical Society continues to reach toward the UMN as a strong ACP community partner. This Mini Bioethics-Academy demonstrates how university departments and the medical society can work together for greater community impact! Barbara Greene, MPH, Director of Community Engagement, Honoring Choices Minnesota.
Visit TCMS at www.metrodoctors.com
By Barbara Greene, MPH
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The Journal of the Twin Cities Medical Society
MMA Annual Conference Held Physicians from around the state, including 70 TCMS members and other physicians from the Twin Cities area, attended
TCMS member Donald Jacobs, M.D. was installed as MMA President.
Drs. Edwin Bogonko and Fatima Jiwa attend Annual Conference sessions.
the Minnesota Medical Association’s Annual Conference, September 19-20, 2014 at Madden’s Resort near Brainerd, MN. In addition to the installation of Donald Jacobs, M.D. as MMA president, TCMS member Edwin Bogonko, M.D. was elected by the MMA membership to serve as a Trustee on the MMA Board of Trustees and Beth Baker, M.D. received the President’s Award for “outstanding contributions to the MMA.” As a result of the three-year suspension of the MMA House of Delegates, approved at the 2013 meeting, a new “Annual Conference” format was implemented. Several CME sessions were offered, in addition to three “issues” forums — Telehealth Expansion, Future of the Health Care Workforce and an Open Issues Forum. TCMS physicians brought forward 13 issues for consideration, including: • Pain Management • APRN Legislation • Medical Liability • Member Input to Legislators • Climate Change • Evolving Role of MMA, MHA, and TCMS • Continuous Annual Commitment to Reproductive Health • Hospital Privileges for Procedures • Oppose Efforts to Ban Gestational Carriers • Opposition to Personhood Bills
MMA Annual Conference attendee Lisa Erickson, M.D.
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John Hitt, MD participates in "Open Issues" Forum.
Medical student Alex Feng and Dr. Stuart Cameron engage in "Issues Forum" topics.
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Telemedicine and Reproductive Health • Upgrading the Position Statement on Abortion to be the Same as AMA • Onerous Insurance Pre-Approval for Surgical Procedures Following a brief dialogue, all forum issues were then forwarded to the MMA Policy Council for consideration. Outcomes of their deliberations are in process at this time. All photos by Kathryn Forss.
Drs. Chris Reif and Sirri Nomo-Ongolo confer during the Annual Conference.
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Address the Sleeping Giant: Effective Prediabetes Managemt for Physicians
D
id you know that almost 30 percent of the U.S. adult population had prediabetes in 2005-2006, and only 7.5 percent were aware they had it? Why does this matter? According to Luke Benedict, M.D., endocrinologist at Allina Health, and speaker at the forum, “Address the Sleeping Giant: Effective Prediabetes Management for Physicians,” it matters as prediabetes increases the risk of development of Diabetes Mellitus 2
(DM2) and cardiovascular disease. As the population becomes less active and eats more calories, the incidence of prediabetes is on the rise. With a grant from the American Medical Association, the Twin Cities Medical Society, Minnesota Medical Association and American Diabetes Association, cosponsored an educational forum on October 7, 2014. The goal was to educate physicians and other medical providers Elizabeth Seaquist, M.D.
TCMS Policy and Legislative Chair Peter Dehnel, M.D., served as Forum moderator.
Panelists: Luke Benedict, M.D., Elizabeth Seaquist, M.D., Gretchen Taylor, MPH, RD, and Sheryl Grover, M.Ed.
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about the incidence of prediabetes, the strategies that can be used to diagnose it and effective interventions to prevent the onset of DM2, including active lifestyle changes through the YMCA’s Diabetes Prevention Project. Elizabeth Seaquist, M.D., 2014 President of Medicine and Science, American Diabetes Association, spoke specifically about the impact of diabetes prevention programs and who benefits most from these lifestyle intervention programs — with and without metformin. She concluded that delaying or preventing Type 2 Diabetes is cost-effective and will help turn the tide on the diabetes epidemic. Thank you to our speakers: Luke Benedict, M.D., endocrinologist at Allina Health; Elizabeth Seaquist, M.D., 2014 President of Medicine and Science, American Diabetes Association; Pennock Chair in Diabetes Research and Professor of Medicine, University of Minnesota; Gretchen Taylor, MPH, RD, Minnesota Department of Health, Center for Health Promotion; and Sheryl Grover, M.Ed, Director of Chronic Disease Prevention, YMCA, Twin Cities Area. MetroDoctors
The Journal of the Twin Cities Medical Society
Student Engagement Twelve second year medical students met with TCMS and MMA staff to discuss opportunities for engagement throughout the school year. In addition to committee involvement, discussion included Lunch and Learn topics, Shadow a Physician, and advocacy.
MMA Annual Conference
The Thomas P. Cook Scholarship was awarded to medical student Maros Cunderlik at the annual Medical School Scholarship Reception sponsored by the University of Minnesota Foundation. Richard Schmidt, M.D., Chair of the West Metro Medical Foundation (of the Twin Cities Medical Society) and Nancy Bauer attended the event, in addition to Maros’ wife, Claudia Manikam.
Photo by Kathryn Forss.
Photo by Stephanie Dunn.
Medical Student Scholarship Awarded
Leah Anderson, MS3, at the MMA Annual Conference.
White Coat Ceremony
TCMS Board member Peter Dehnel, M.D. addresses the 2017 Medical Student Class and presents each with an ADC Buck Hammer. MetroDoctors
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In Memoriam ANN M. BUTTWEILER, M.D., age 59, passed away on September 2, 2014. Dr. Buttweiler attended the University of Minnesota Medical School and practiced obstetrics and gynecology. Dr. Buttweiler became a member in 1984. STANLEY SHAPIRO, M.D., passed away August 3, 2014 at the age of 81. Dr. Shapiro attended the University of Minnesota Medical School specializing in psychiatry. Dr. Shapiro became a member in 1963. ERNEST W. SWIHART, M.D., passed away September 18, 2014. Dr. Swihart was one of the founders of South Lake Pediatrics where he practiced as a behavioral pediatrician. Dr. Swihart became a member in 1975.
New Members Byron J. Marquez, D.O. HCMC Whittier Clinic Family Physician John P. Scanlon, M.D. HealthEast Midway Clinic Internal Medicine
EBOLA Educational Forum Event Tuesday, November 18, 2014 5:30 to 7:30 p.m. University of Minnesota Continuing Educ. & Conf. Center
1890 Buford Ave. St. Paul, MN 55108 Registration is FREE! Speakers: Aaron DeVries, M.D., MPH, Medical Director of Disease Epidemiology, Prevention and Control Div., Minnesota Department of Health Wendy Slattery, M.D., Medical Director of Infection Control, Allina Health John Hick, M.D., MBA, Medical Director of Emergency Preparedness, Hennepin County Medical Center Peter Bornstein, M.D., Moderator, Epidemiologist, HealthEast Event Sponsors: Twin Cities Medical Society Minnesota Medical Association Minnesota Department of Health Minnesota Hospital Association HealthEast Care System Hennepin County Medical Center
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November/December 2014
31
LUMINARY of Twin Cities Medicine By Marvin S. Segal, M.D.
KENT SHANNON WILSON, M.D. OUR LUMINARY WAS RECENTLY ASKED, “What has
been the most favorite aspect of your long and varied career?” He replied, “I enjoyed it all, but the most gratifying part has been recognizing and acting upon those aspects which have the largest potential social benefit and which have not been completed before.” Let’s explore how Dr. Wilson’s many accomplishments have clearly demonstrated how well this “trailblazer philosophy” has benefited his patients, colleagues and community. Dr. Wilson started life in Bemidji, the son of a school athletic director, and later earned his B.S. and M.D. degrees at the U of M. There followed U.S Public Health Service work in Louisiana, and then five years in ENT residency, research and fellowship training here at his alma mater. His base of operations became St. Paul, where he and his growing family settled. His private ENT practice spanned 32 years — during which time he held many administrative and leadership positions. Among those was an editorship of the Journal of History of Medicine, surgical department chairs at St. Joseph’s and Children’s Hospital, and Presidencies of the Minnesota Academy of Medicine, Children’s Hospital Staff, his private practice group, the MMA, and the Minnesota Academy of Otolaryngology. Kent’s youthful life was filled with athletics and he noted then and in his early professional career that facial and ocular injuries were inordinately common and especially dangerous in the sports of hockey and football. He educated himself on the topics of maxillofacial and ophthalmic trauma, performed needed research in those fields and assertively proposed the widespread use of facial masks and dental guards for those athletes. Dr. Wilson was instrumental in the eventual acceptance and official compulsory implementation of these safety features via the State High School League and our state legislature. Countless significant injuries have undoubtedly been averted as the result of those efforts. In addition to sports-related facial trauma, Kent presented and wrote about a variety of head and neck topics including sinus endoscopy, snoring and sleep apnea, the cervical lymphatic system and pediatric airway management. His ENT update courses through the years were 32
November/December 2014
well attended and extremely popular. Dr. Wilson’s family and community pursuits, requiring significant energy and time, were parallel to his professional activities. From boat building to opera production, family and European historical heritage genealogy study and hosting of the Czech Head of State — yet he still found time to regularly transport his grandchildren to various church-related activities. While leading the East Metro Medical Society Foundation, and in search of a meaningful project, he happened upon a successful Advanced Directive program (Respecting Choices) in LaCrosse, WI. Sue Schettle, our TCMS CEO, states, “Dr. Wilson saw the bigger picture, personally investigated the Wisconsin operation in advance of modifying it to better fit the more urban Twin Cities environment while energetically founding Honoring Choices. His inspirational approach was like a ‘lightening bolt’ in the development of this highly successful program.” Both the number of participants and acceptance by our clinical community have increased markedly since its inception. It’s an acknowledged fact that Honoring Choices simply wouldn’t be where it is today without his efforts. It’s abundantly clear that Kent has repeatedly fulfilled that favorite portion of his career — blazing new, successful and exciting trails. He is the consummate professional, a loving family man and a giving community member . . . What a guy! What a Luminary! This last page series is intended to honor esteemed colleagues who have contributed significantly to Twin Cities medicine. Please forward names of physicians you would like considered for this recognition to Nancy Bauer, managing editor, nbauer@metrodoctors.com.
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This Thanksgiving, carve out time to have the conversation www.HonoringChoices.org 速 An initiative of the Twin Cities Medical Society.