CommunicationReview of Systems

An Aid for Caring for the Seriously Ill

South Carolina Healthcare Ethics Network Annual Meeting

Summit on Care of the Seriously Ill

Mark A. O’Rourke, M.D.

October 12, 2011

Communication Review of Systems (C-ROS)

1. Ability to Consent

2. Patient Voice

3. Physician Voice

4. Patient Understanding

5. Physician Understanding

6. Advance Directives

7. Decisions

Case for Improved Communication, Consent and Decision-making

Experience with hospital ethics committees in South Carolina, communication problems are frequently the beginning of disputes with patients and families.

End-of-Life Transitions among Nursing Home Residents With Cognitive Issues, Gozalo P et al, N Engl J Med 2011;365:1212-21, September 28, 2011.

Burdensome transitions are common, vary according to state, and are associated with markers of poor quality in end-of-life care.

Ultimately, a decline in burdensome transitions will come about through a combination of:

Improved provider incentives, and Decision making that elicits and respects the needs of the choices of the patients.

Reducing Unnecessary Hospitalizations of Nursing Home Residents, Ouslander JG et al, N Engl J Med 2011;365:1165-67, September 28, 2011.

Change financial incentives to hospitalize a patient from a nursing home. Improve acute care in nursing homes, including communication strategies.

Variation in Rates of Burdensome Transitions among 474,829 Patients, According to State.

Gozalo P et al. N Engl J Med 2011;365:1212-1221

State Variations in the Proportion of Nursing Home Residents with Advanced Cognitive Impairment Who Had at Least One Burdensome Transition.

Gozalo P et al. N Engl J Med 2011;365:1212-1221

Unavoidable and Potentially Avoidable Hospitalizations of Nursing Home Residents Eligible for Both Medicare and Medicaid, 2005.

Ouslander JG, Berenson RA. N Engl J Med 2011;365:1165-1167.

Case for Improved Communication, Consent and Decision-making, p.2

Patient and Family Surveys, including the SUPPORT study. Physicians speak out:

Levinson W et al. Physician Communication, It’s About Time. JAMA 2011;305:1802-03. Astrow AB et al. The Palliative Care Information Act in Real Life. N Engl J Med 2011;1885-87. Billings AJ et al. On Patient Autonomy and Physician Responsibility in End-of-Life Care.

Archives Intern Med 201;171:849-53. Zeytinoglu M. Talking It Out: Helping Our Patients Live Better While Dying. Ann Intern Med

2011;154:830-32. Proposed solutions:

Physicians should take more time to communicate better. Medical schools should improve how they teach communication. Medicare, Medicaid, and health insurance companies should reimburse physicians better for the

time and effort spent in communication. Academic medical centers could apply the science of quality improvement to analyze

“communication errors” and develop quality improvement plans.

Controlling Death: The False Promise of Advance Directives. Henry S. Perkins, MD Annals Intern Med 2007;47(1):51-57

“Advance directives simply promise more control over future care than is possible. Unexpected problems arise repeatedly to defeat advance directives.”

“I conclude that, while drawing lessons from advance directives, advance care planning must evolve beyond them.”

“Advance care planning must refocus from completing advance directives to preparing patients and families for the uncertainties and difficult decisions of future medical crises.”

Communication Review of Systems (C-ROS)

A clinical tool Part of the History and Physical Exam with

Present Illness, Past History, Family History, Social History, (physical) Review of Systems

Completed by the physician, like the H&P, when a patient is admitted to the hospital

The admitting physician may get help from the multidisciplinary team.

Communication Review of Systems (C-ROS)

1. Ability to Consent

2. Patient Voice

3. Physician Voice

4. Patient Understanding

5. Physician Understanding

6. Advance Directives

7. Decisions

Ability to Consent Determine the patient’s mental capacity to consent to

care and to procedures in the hospital. A patient interview is a helpful first step. Care partners, prior documentation or documentation of legal incompetence may help as well.

If the patient is not able to consent to care and procedures, determine the appropriate person who is.

Patient Voice If the patient is able to consent, determine who the patient

has, or wants to have, to help with consent, communication, and decision-making. The patient voice may be the patient alone, but may include a care partner. The care partners may be a spouse, fiancé, partner, parent, child, sibling, friend, associate, caregiver, or a significant other person.

The patient may already have designated a spokesperson in writing.

When many care partners are involved, agreement on one to be the point person for ongoing communication with physicians may help.

Physician Voice Determine who are the various physicians or

physician groups involved in the patient’s care. In addition to the admitting physician, there may be multiple consultants, including hospitalists.

Identify for the patient and care partners which physician will play the lead role in managing the patient’s care while in the hospital.

Determine which physicians outside of the hospital are involved in the patient’s care for purposes of communication and coordination of subsequent care.

Patient Understanding Determine the patient’s and care partners’

understanding of the patient’s situation in the hospital. Open-ended questions help patients and care partners express their understandings, beliefs, values, and emotions.

Topics to ask about include the reason for admission, events during the hospital stay, and the patient’s health prior to admission.

Additional topics to ask about include expected outcome and prognosis for this hospital stay and in the future.

Physician Understanding Determine, articulate, and explain the physicians’

understanding of the patient’s situation in the hospital, to include the reason for admission, events during the hospital stay, and the patient’s health prior to admission. Additional topics to address include expected outcome and prognosis for this hospital stay and in the future.

Advance Directives Determine whether patient has any advance

directive documents. Ask whether the patient would like information about advance directives or to complete advance directive documents.

In 2010, South Carolina law provides for several documents: Living Will (Declaration of Desire for Natural Death) Health Care Power of Attorney

Five Wishes

Decisions Determine what decisions may need to be

made immediately or later during this hospital stay.

Arrange the schedule and manner of communication between the physicians and the patient and care partners during this hospital stay.

Why will the C-ROS help with Communication, Consent andDecision-Making in hospitals in SC?

The Communication Review of Systems is a uniform process.

A uniform process can change the medical culture for: Physicians and others in a hospital system Hospitals across the state Physicians and others over the continuum of training

Medical school Postgraduate training In practice

Patients at various times, with various physicians, at various hospitals, under various circumstances.

Communication Review of Systems (C-ROS)

1. Ability to Consent

2. Patient Voice

3. Physician Voice

4. Patient Understanding

5. Physician Understanding

6. Advance Directives

7. Decisions

C-ROS Example: 65 y/o female admitted with weakness, weight loss, and Hb 6.0.

1. Consent: Mrs. Carlson has had capacity to consent, but she is lethargic and having difficulty processing information.

2. Patient Voice: Patient lives alone, with her oldest daughter nearby. She is relying mainly on her daughter for support at this time.

3. Physician Voice: Dr. James is the hospitalist and admitting physician. He will be the lead physician, and the consultants will report to him. Because of suspected blood loss in the intestines, a gastroenterologist will be consulted. If it appears that surgery might be necessary, a surgeon will be consulted. Dr. James or one of his partners will see the patient each morning on rounds, around 7:00 am.

C-ROS Example: 65 y/o female admitted with weakness, weight loss, and Hb 6.0, p.2

4. Patient Understanding: Mrs. Carlson does not go to doctors regularly. She thinks that her condition is caused by stress in her job at a convenience store.

5. Physician Understanding: Dr. James is concerned that the patient might have a bleeding ulcer or maybe a cancer of the intestines.

6. Advance Directives: Patient does not have a living will or a HCPOA. If she cannot speak for herself, she would like for her daughter to make decisions for her.

7. Decisions: Mrs. Carlson may want to learn about and consider a health care power of attorney and/or a living will.

C-ROS Example: 45 y/o male with history of HIV, remote history of lymphoma, and recent history of pneumonia, admitted with pain, inanition, altered mental status, lung nodules and a liver mass

1. Consent: Mr. Dean is delirious. His male partner came with him to the hospital. There is apparently no HCPOA or guardianship.

2. Patient Voice: He is divorced. He relies on his domestic partner of 16 years. His father and mother live locally, but are estranged and are uncomfortable with the partner.

3. Physician Voice: Dr. Jenkins is the admitting hospitalist. The ID doctors know the patient and consider him a noncompliant sociopath. The patient does not have a primary care physician or a medical oncologist. Dr. Jenkins is the lead physician.

4. Patient Understanding: He was treated for lymphoma in another city five years ago, but does not recall the name of the facility or the doctor. He does not know why he is in the hospital.

C-ROS Example: 45 y/o male with history of HIV, remote history of lymphoma, and recent history of pneumonia, admitted with pain, inanition, altered mental status, lung nodules and a liver mass, p.2

5. Physician Understanding: Dr. Jenkins knows that the patient is weak with undertreated HIV and the masses in the lung and liver. If the patient has a malignancy, it is not at all clear how successful any treatment might be.

6. Advance Directives: No known living will or HCPOA.7. Decisions: Make an immediate effort to involve the parents who

are the next of kin. . Meet with parents and domestic partner to determine lead decision-maker. Note that the person with higher priority as surrogate under the SC HealthCare Decisions Act may delegate authority for decision-making. There is a definite problem with consent and decision-making. Consult the palliative care service (or ethics committee consultation if palliative care consultation is not available). Get oncology consultation to determine if there is a malignancy and, if so, the prognosis.

Communication Review of Systems (C-ROS)

1. Ability to Consent

2. Patient Voice

3. Physician Voice

4. Patient Understanding

5. Physician Understanding

6. Advance Directives

7. Decisions

Focus on Seriously Ill Inpatients

Focus on Seriously Ill Inpatients Kelly AS, Morrison RS et al. Determinants of Treatment

Intensity for Patients with Serious Illness: A New Conceptual Framework. J Pall Med 2010;13(7), online August 4, 2010, DOI: 10.1089/jpm.2010.0007

The inability to accurately predict life expectancy for individual patients with serious illness, the innate human struggle to avoid death, and modern political realities pose challenges to policies designed to improve end-of-life care. Instead, reform efforts should focus more broadly on all patients with serious and life-limiting illness. Therefore, we propose a new conceptual framework to guide research and policy aimed at enhancing healthcare efficiency and promoting goal-directed care of patients with serious illness.

Focus on Seriously Ill Inpatients

Focus on Preparing Patients for Decision Making

Sudore RL, Fried TR. Redefining the “Planning” in Advance Care Planning: Preparing for End-of-Life Decision Making. Ann Intern Med 2010; 153:256-261 (17 August 2010)

“Given the problems with prespecified treatment preferences, we propose that the main objective of advance care planning be to prepare patients and surrogates to participate with clinicians in making the best possible in-the-moment decisions.”

“This approach does not preclude the completion of an advance directive but recognizes that it is just one piece of information to be used during in-the-moment decision making.”

C-ROS Summary

The C-ROS is a communication checklist. It needs to be studied and tested like any other checklist or quality improvement process.

The C-ROS is simple, inexpensive, and intuitive. How to administer the C-ROS:

Start with “For medical issues, who would you want to speak for you if you could not speak for yourself?”

Ask “Do you have a Healthcare Power of Attorney?” Then explain what it is, etc.

South Carolina Coalition forCare of the Seriously Ill

The SC Coalition for the Care of the Seriously Ill (SC Coalition CSI) is comprised of clinical and administrative leaders representing key statewide organizational partners, healthcare entities, and individuals that have agreed to collaborate in a major statewide initiative to redesign care, improve quality of life, and protect the ethical rights of the seriously, chronically, or terminally ill in S.C.

Members of the Coalition for 2010 include: South Carolina Medical Association The Carolinas Center for Hospice and End of Life Care the South Carolina Hospital Association the SC Healthcare Ethics Network The S.C. Society of Chaplains LifePoint AARP South Carolina Nurses Association

South Carolina Coalition forCare of the Seriously Ill - Charter

Vision Statement: SC delivers excellent communication and shared decision-making for persons with serious, chronic, or terminal illnesses.

Mission Statement: All persons in SC with serious, chronic, or terminal illnesses will have an active voice in the care decision process.

The Coalition will set the vision, mission,and strategic aims and will provide guidance and monitor the impact and value of its work.

It will also seek grant funding to accomplish the strategic aims and promote alignment of public policy with the Coalition’s mission.

SC Coalition for the Care of the Seriously Ill --- Project List

Template hospital policy, entitled Communication, Consent, and Decision-Making Process for Seriously Ill Inpatients, and the template progress note, entitled Allow Natural Death or Limited Resuscitation. This is in the process of adoption and implementation at MUSC with the active involvement of Dr. Walter Limehouse.

Communication Review of Systems (C-ROS). It is a clinical tool that complements the template policy and progress note. It is in the process of pilot testing at Greenville Hospital System under the leadership of Dr. Mark O’Rourke.

Palliative care bundle (Nelson JE, et al.  Improving Comfort and Communication in the ICU: a practical tool for palliative care performance measurement and feedback.  Qual Safe Health Care 2006;15:264-271), currently being introduced at Roper-St. Francis in Charleston under the leadership of Dr. Scott Lake. It is a tool that records data on ten parameters found in the medical record to assess the quality of palliative care in an ICU over time.

SC Coalition for the Care of the Seriously Ill --- Project List

Document to be called the South Carolina Palliative Care Resource Toolkit.

Adoption of uniform language in hospitals across the state for the documentation of the status of an inpatient with regard to cardiopulmonary resuscitation.

Development statewide of advance directives in the form of physician orders for life sustaining treatment (POLST) that can accompany a person from an outpatient setting, such as a nursing home, to an inpatient setting.

What Is Palliative Care?

Medical treatment that aims to relieve suffering and improve quality of life simultaneously with all other appropriate treatment for patients with advanced illness, and their families.

Domains of Palliative Care

Communication, help with medical decision-making

Expert symptom assessment and treatment

Psychosocial and practical support, care coordination, and bereavement services

Stages in the Continuum of Palliative Care

Curative Care

Active Palliative

Symptomatic Palliative

Supportive Palliative

PatientGoal

Cure Prolong life/

Survive

Comfort Comfort

DiseaseGoal

Eliminate Arrest/

Control

Some Control

No Control

Mind Set Win Fight Hope/Live with it

Acceptance

CPRAppropriate?

Yes Probably Varies No

HospiceAppropriate?

No No Maybe Yes

The Center to Advance Palliative Care (CAPC)Provides health care professionals with the

tools, training and technical assistance necessary to start and sustain successful palliative care programs in hospitals and other health care settings.

CAPC is a national organization dedicated to increasing the availability of quality palliative care services for people facing serious illness. www.capc.org

Director: Diane E. Meier, MD, FACP