BREAKING THE ICE ON END-OF-LIFE CARE

by Emily Wittenhagen

Organization: WSMA
Project Name/ Title: Honoring Choices Pacific Northwest
Point of Contact: Jessica Martinson, jessica@wsma.org

I was happy recently to sit down for a talk with Jessica Martinson, ‎the Director of Clinical Education and Professional Development at the Washington State Medical Association, known to many in our state as WSMA (pronounced wizma).

ABOUT THE WASHINGTON STATE MEDICAL ASSOCIATION
WSMA represents over 10,000 physicians, resident physicians, medical students and physician-assistants throughout Washington State, the only professional organization in the state that represents the interests and priorities of all physicians, regardless of specialty or practice type. WSMA’s mission is to provide strong physician leadership and advocacy to shape the future of medicine and advance quality care in Washington State.

DESCRIBE THE PATIENT SAFETY CONCERN YOU OR YOUR ORGANIZATION WAS AIMING TO EFFECT
Jessica has worked since 2014 on the Honoring Choices® Pacific Northwest initiative. Co-sponsored by WSMA and the Washington State Hospital Association, this collaborative effort between physicians and hospitals will ensure that health care providers are prepared to discuss and honor patients’ end-of-life wishes. Honoring Choices PNW is one of the biggest rollouts of an advanced care planning program in the country and works in partnership with Respecting Choices, an internationally recognized evidence-based model of advance care planning (ACP). The first cohort on the project is made up of 32 teams from 23 healthcare organizations, representing every major healthcare system in the state, as well as rural and critical access hospitals and medical groups.

DESCRIBE THE CHALLENGES YOUR TEAM OR ORGANIZATION FACE. HOW DID YOU OVERCAME THESE BARRIERS?
CHALLENGE #1: LACK OF URGENCY
To begin with, the Honoring Choices PNW team is focused on First Steps® conversations with healthy adults. While advance care planning is not the “biggest fire burning” for adults when they are happily enjoying good health, this is precisely the right time to get the conversation going.

Instead, the reality is that many people don’t think to have these conversations until it’s too late, if they have them at all. Sometimes the conversations happen after a serious diagnosis. But all too often we see the worst-case scenario: a person has a medical emergency and they cannot speak for themselves, leaving their families to guess what kind of care their loved one may want.

SOLUTION: BUILDING URGENCY
“To address that,” Jessica says, “we have to move the conversation upstream.” As the saying goes, “It’s always too early until it’s too late.” A key strategy is to have healthy adults think about a sudden illness or accident that leaves them unable to communicate. Even the most invincible person can relate to that type of scenario. The aim is to demonstrate the importance of having these conversations long before people think they need to have them.

CHALLENGE #2: LACK OF INTEGRATION
Advance care planning is not yet fully integrated into routine care.

SOLUTION: INTEGRATING BOTH TOP-DOWN & BOTTOM-UP LEADERSHIP
Jessica’s team is engaged in an intensive initiative to get advance care planning integrated into routine care. The first step was to ensure leadership engagement. Although the need was clear, the team was surprised by the overwhelming demand to join the first cohort. Once the leaders signed on, front-line staff were eager to get to work designing and implementing their customized advance care planning programs to ensure the conversations were part of routine, patient-centered care. The strong mix of both top-down and bottom-up leadership is a key ingredient for success.

“The thing I like the most about this program is that it takes a systems-based and team-based approach to integrating advance care planning into routine care. It should be as routine as taking someone’s blood pressure or making a referral.”

Implementing a strong ACP program means changing workflows, training staff and changing EMRs. Jessica has high praise for the over 200 front-line staff who are doing the nitty gritty work of putting this work into practice. “They deserve all the credit,” she says. “It’s hard, disruptive work. It takes persistence and patience. They’re doing an incredible job.”

CHALLENGE #3: LACK OF TIME
Physicians don’t have time to have lengthy conversations with each one of their patients about their values, goals, and preferences related to end-of-life care.
SOLUTION: RECRUITING A TEAM
The ACP program relies on a team-based approach, supporting physicians by certifying ACP facilitators to have in-depth conversations in their stead. The role of the physician is to motivate their patients to have a conversation and then refer them to a facilitator. Following the conversation, a summary of the key decisions and a list of clinical questions go back to the physician for follow up if needed.

“It’s always too early until it’s too late.”

WHAT WERE THE BIGGEST CONTRIBUTORS TO THE SUCCESS OF THIS PATIENT SAFETY PROJECT OR INITIATIVE?

• Employing “A Small Test of Change”
  Honoring Choices PNW has the care teams start small – an approach called the “small test of change” – and begin by having one or two doctors in a clinic integrate advance care planning into their routine care. The team can more easily assess what works and what needs changing, establish best practices and work flows, and then spread it to other clinic staff. In addition, organizations choose new sites to disseminate the work in a step-wise approach until everyone in the organization has adopted the practice.
• Leadership Engagement
  The Honoring Choices PNW team engaged with the WSMA & WSHA Medical Officer Collaborative, made up of Chief Medical Officers (CMOs), Vice Presidents of Medical Affairs (VPMAs), Chiefs of Staff, and senior-most physicians. These leaders are enthusiastic to make the advance care planning initiative one of their calls to action, supporting it for regional adoption, and prioritizing it within their organizations.A bonus of the collaborative is its built-in accountability. The group meets three times a year to report on the progress of their work, how it’s being implemented, and any barriers they are struggling against. Jessica credits these meetings with helping develop a sense of ownership for the work and says they are one of the biggest contributors to the initiative’s success, emphasizing one of their main philosophies: “The front line cannot be successful if they do not have leadership support.”

 
WHAT IMPLEMENTATION LOOKS LIKE IN PRACTICE
Most commonly, patients are invited during the annual wellness visit by the physician who uses some key phrases designed to spark the conversation. For instance, a patient might be asked if they’ve identified a person (e.g. a durable power of attorney; typically a family member or loved one) to speak for them should they ever be in a position in which they can’t speak for themselves. It only takes a couple of minutes for the physician to make the invitation. Following this, if the patient is motivated to participate in further discussion, they are referred to a facilitator.

Advance care planning facilitators undergo a formal certification process in which they are taught to guide patients in thinking about their values, goals, and preferences for end-of-life care. One-on-one consultations typically take an hour, and the presence of the health care agent is encouraged as the “gold standard.” Facilitators follow a guide or roadmap to lead the patient through key questions: who should be your health care agent, what gives your life meaning and what type of medical treatment would you want if you had a sudden event that left you unable to communicate. The focus of the conversation is on exploring acceptable vs. unacceptable outcomes rather than answering ‘yes’ or ‘no’ to whether they would want specific medical interventions.

WHAT WERE THE PRIMARY OUTCOMES OF THIS WORK?
The Honoring Choices PNW team set several goals for organizations to meet. Three main goals stand out: 25% of conversations have a healthcare agent present, 95% of conversations are documented by a facilitator in the Electronic Medical Record (EMR), and patients rate the conversation as 4 out of 5 or higher. Organizations are well on their way to reaching and exceeding all three of these goals.

Ultimately, organizations will be able to show that their patients receive care at the end of their lives that match their goals, values and preferences.

WHAT WERE THE BIGGEST LESSONS LEARNED IN THIS EFFORT?
The effectiveness of:

• Open team collaboration: Teams from a variety of organizations participate in group consultations and share in real time the barriers they face and how they are overcoming them.
• Regular data reporting: Teams report monthly on 13 measures. One of the benefits is that a team struggling in one area can benefit from hearing solutions from another team or organization that is having success in that area.
• Positive peer pressure: Sharing data transparently puts positive pressure on everyone to excel. Jessica says this has made a major impact on the initiative’s success and was made possible because so many organizations are participating at once.

WHAT WERE THE REACTIONS OF PATIENTS, FAMILIES, AND/OR STAFF EFFECTED BY THE WORK?

• “Great facilitated service. Everyone should have this planned or recorded with their medical record.”
• “This session was invaluable for me.  She took some very complex topics and helped me really understand them.”
• “It was so helpful to hear myself say my wishes out loud.”
• “She made it very comfortable to talk about decisions that may be difficult.”
• “Great job of listening and then restating what she heard. She was able to ask probing questions to get deeper insight.”
• “Thank you for your patience with my tears.  It was unexpected and you made me feel normal and safe.”
• “The facilitator was the perfect person to ask these hard questions about end of life. She was warm, comforting and very easy to talk with. Very happy I came today.”

Source: The Vancouver Clinic

IF ANOTHER ORGANIZATION WERE TO JOIN THIS INITIATIVE, WHAT WOULD BE YOUR BIGGEST SUGGESTION?
Jessica’s biggest suggestion would be to start with strong leadership engagement, a clear understanding of expectations, and commitment from front-line clinicians and staff.

A beautiful “side effect” of this work is that employees find it to be incredibly fulfilling and that it adds to their job satisfaction. Imagine a Medical Assistant who gets to deepen her relationship with a patient by talking about something so intimate in a safe space. Many physicians credit discussing end-of-life care with their patients with reminding them why they went into medicine in the first place. Some even describe it as a “burnout buster.”

It turns out, having what many imagine to be a difficult conversation can be quite fulfilling, for both patients and staff – a win-win that seems well worth the effort.

This post was written by Emily Wittenhagen, Marketing & Communications Manager for WPSC, with collaboration from Jessica Martinson and Graham Short of WSMA.