How To Sign Oregon Banking Medical History

How to industry sign banking oregon medical history

thank you so much and I love all the history with palliative care and hospice that was mentioned too so so we're going to get started and it's going to be back to where you started so thank you for the history there of me so I just want to thank a lot of people who helped make this possible we have nothing to disclose that one think dr. Dunn who's actually here's where the palliative care physicians at Norton's hospital for some of his slides and Betty Robison VJ one of our resins that really helped me with these screen shots I'm not the most technically and find and so it was great to have some assistance so exam I'm going to talk about the importance of advanced planning advance care planning I just have to point out one thing if you notice there's no D on the end of that advance because you do it in advance like it's prior to when you actually need it so it's just a little technical thing but just just when you say advance care planning don't put the D on it and I also just one technical thing I noticed on some of the Flyers that said I was the program director for the power nose and fellowship I'm no longer the family's answer for the palliative medicine fellowship Mary Huber it is so thank you Mary for taking that over because where the role is to talk about how to have a goals of care discussion and we're going to go over the techniques but if you really want to practice and learn more today from 11:30 to 1 this is national healthcare decisions through in week and month and a Jewish Hospital in the fixed auditorium which is behind the cafeteria there at Jewish by the chapel we're gonna have a session a little bit like this but specifically let people practice having this advanced care goals of care of discussion we're going to teach you how to complete a most form so we'll go over that and we're going I'm going to tell you how to document the most for me HR which is very complicated so hopefully we'll make it much easier so first I want Justin Magnuson to speak he is our most coalition and palliative care liaison for the Institute for sustainable health and optimal aging and this is a picture of him as a grandmother so he'll tell you a little about that we always want to start with a case or story so this is our case and our story so this is Justin thank you dr. Thurman if you can tell by this picture it's probably 1984 by my Michael Jackson t-shirt I am eight years old and I'm with my grandmother if you pan back you would see that we're standing in front of route and Mount Rushmore and my grandfather is taking the picture so at this age how many conversations around end of life discussions do you think my grandmother and I have had probably zero well flash-forward 17 years and I am her only surviving kin and guess how many end-of-life conversations we've had to that point 1/2 of 1 it's a Friday afternoon we have lunch she is 80 years old I am 25 on the way home from lunch we're driving through this small town and she says by the way I have a CD in that Bank and I have an insurance policy right there and I that's very nice grandma we get to the four-way stop in Palmyra Indiana where she's lived independently since the 70s and she says by the way I have a bank account there and my funeral arrangements are there great grandma we get home she says be to the houses in this box check books in this box you can write checks and I am do not resuscitate so that's the half part of the conversation that night she drives herself to the hospital doesn't call us Sunday we get a call from her next-door neighbor where she's in a small County Hospital out in heret Harrison County basically my grandma's been there for two days and she was incoherent by the time we got there on Sunday evening I walk in so you had the picture at 25 my hair was about down to here and I had a big bushy beard and I'm all of a sudden getting the crash course and had a navy navigate the healthcare system and they keep looking to my father to make the decisions and it took a long time to really get it across that it's like my dad was there that support me and help me make decisions but when it came down to it I was the one that was there every day making these decisions and over the last five weeks of my grandmother's life I got to make a lot of decisions and I had support but at the end of the day I was the one that was having to go in and talk I got to here by my grandmother sexual health history I got lots of things that a 25 year old typically doesn't have the opportunity to do and over the course of that I saw the shortcomings of our own planning I saw the shortcomings of our own discussions around this but then I also got a lot of just mixed messages about her prognosis and diagnosis I got a lot of hesitancy of really talking about what was really going on and a week before she died she was refusing to eat and she was talking to my great-grandfather and it was never discussed that hospice and palliative care might be appropriate so over the course of that experience I got a really good hard look at what it is to care for somebody at the end of life and you had no discussions and it gave me a lot of passion to learn about how we can communicate this interpersonally but then also between professionals and the can the patients and patients and their families we just need to do a better job at this is a culture and I feel really blessed to work with dr. Furman and the Institute and the most coalition on getting out and doing these conversations so I really you know want to welcome Christian back up to talk about goals of care conversations and how this fits into documenting these these really important conversations thank you so much Justin because I think yeah we don't really make it hard on the family we want to make it easy on the family we want to have this to be normalized and so I think our job as physicians is to make it happen so we want to make sure we improve the health and well-being of our patients patients need this information we want improve system outcomes if you do advanced care planning you know before we started the palliative here fellowship and had sort of powdery care at the VA and I remember and the doctors parking lot whatever it was leave them you know at for $5.00 VA and one of the faculty have been faculty a renal faculty attending for a long time and he came up to me and he was like thank you so much for starting palliative care because he said I knew I wasn't doing the right things that I wasn't I shouldn't be dying I think he's being prepared in stage dementia you know dying people I didn't know what else to do you No and now I can actually affirm the palliative here so we wanted these system outcomes to improve and I think we have to have this process in place so we can do the right thing we know what the right thing to do is it's also cost-effective it m it addresses the Triple Aim the Triple Aim is better patient care but okay better care for the patient they don't care for the community and a lower cost and so that's what we're trying to do so this is some good research this was on doctor Tino and her colleagues found that in the last month of life 50 percent of older adults go to the emergency room and 75% are hospitalized and 66 percent died in the hospital so really last month of life you know you really wouldn't be in the hospital not necessarily if you really talk to people Ferguson and Medicare patients receive ICU here in the last month of life the problem is if the mood of the last month alive maybe them I think no one really knows it's the last month of life he had a crystal ball but there are a lot of ways we could know is the last month of life if we were paying attention and at the end of life in the last three days of life only 25% receive hospice care when they only have three days to live we want hospice to be involved six months beforehand not three days beforehand and 80 percent of people if you ask and want to die at home and just think about yourself like if you're thinking about how I'm gonna die like no one wants to think about it but people have a burst plan so you it's okay to have a death claim they're gonna think about like how do I want to die do you want to die hope definitely I see like you personally you know most people think I just want to die at home you know Barbara Bush died yesterday from the day before and she died at home in her house in Houston so if you think about most who want to die at home but actually more than 50% of people die in the hospitals in the United States so this is what we're trying to address and this is why advanced care planning is important so these are some good visuals and these are slides that dr. Dunn came up with but you know on the left this is dying well is living well so you know we want to live the best life you can it's not really about Dynes about living and hospice has those great commercials about people you know fishing and as they're dying and you can still fish when you're dying you can still hike when you're dying you can still enjoy your family when you're dying just bottom-1 everybody's like jumping around you know around a dying patient so you want to be around people but what happens a lot of times is right hand side you know people die by themselves and the ICU hooked up to machines know the nurses beside them but you know very strange he wants to die we strange you know so we're trying to get away from this right hand side and the way to do it is to plan ahead and have an advanced care plan and you think who should you be having these conversations with really everybody everybody over the age of 18 but even in Pediatrics you know some 16 year olds can have these conversations or it depends it's not really age it's really developmentally how are people able to have these conversations but for sure prior to diagnosis like when it's calm and peaceful and doctor's office is an outpatient children born with debilitating or life-limiting illnesses the doctors and the paint and the family should be having these conversations everyone before you go do lodge and have this conversation you know crazy things can happen you want to make sure you know what the wishes are I wonder if Justin's grandmother had a in cleaning what was going on and she was pointing out things you know so people kind of have a sense and so they won't tell you these things they're so talking to you about these things you need to listen anyone with a chronic disease you never know and that chronic disease is going to just turn south and go bad so you know there's tons of examples and they should have an advanced care planning conversation and so this is a good slide they kind of talk about when and how palliative care can be involved in this really part of care should be involved at the time of diagnosis right here business diagnosis a little bit right if the diagnosis should be palliative care you know advance care planning do you have a little role who's your health care surrogate if something goes Bob you do I'll call but most of those up here when you're doing the medical management of the chronic illness but as time goes on this is time you know it does become more that you should be doing a lot lot more palliative care you so you want to manage the illness you know sometimes the curative care is the palliative care and congestive heart failure like staph the toy rabbits then we try to keep from so they're not short of breath I mean that is palliative care we don't want people to be short of breath the last 12 months you know there is usually a goals of care shift if people are so keen in planning and starting to figure out what the prognosis is and there's lots of research to know how to prognosticate and then when people die I'm sorry the dog here's for the last nice before they die is really when you can get hospice involved that's just because that's what the House and Senate voted on one time to say this is what the hospice Medicare benefit should be at six months there's no magic to six months you know it's just what financially the house and the Senate thought would work from actuarial data so and then after someone dies there's a bereavement period and you should follow them hospice officially follows people for 13 months after someone dies there was 13 months get you through all those milestones that one year at death is so hard and so that's why they pick 13 months so you can see how double counting curative care can coexist advance care planning can exist through all this okay so do do advanced care planning and figure out the size you have to have this conversation and this is the hard conversation but just know if you have this conversation it saves time saves money whoops relieves everybody it's it's good so we're going to talk about when does it goals of care need to be established who needs to participate talk about the details of how to have this discussion we're going to talk about specifically the DNR discussion and I would propose and I'm not the first one I didn't come up with this instead of second DNR do-not-resuscitate something regular like they're not going to get something some people in our healthcare system have been done denied medical care their whole lives and by god I believe you didn't appear so if you so do not do something so don't do something it's back so it's to be more positive it's a loud natural death it's a normal thing it's okay to die and you can a lot of hospital systems and health care systems are going to A&D allow natural death that's a positive you're not going to deny anybody anything and a lot of this is from dr. Wiseman and this is what Barbara's talking about he came and gave a lot of a game presentation and it's still appropriate so we can do this any way you want and muddle through it and it'll go bad probably so I've encouraged you to use a technique and kind of do it the same way all the time so you know when you're in the hospital you should have this conversation I give this example the time when I was a new faculty made my first or second year in one of my partners was dr. Pat Murphy at North who knows dr. Murphy he's he's still working mostly retired but so you know he was in the hospital I was in the al page study and I had a new patient I've done the whole Agent P you know I knew a mammogram was I knew your last mammogram was I know she smoked and you are the details and he said here this patient in the hospital he's like Christian so what's her dance director does she want to be a fur coat or DNR or what I'm like COPD suck why don't you ask her about her advanced directives no like I'm sorry so you know don't live in the house above for sure when you're doing it admission Agent P in the hospital you ask them all kinds of other questions ask them what their the instructors are maybe they have in a lockbox somewhere that they told their grandson you know five years ago so you need to ask these questions when the patient has a chronic exacerbation that's a good time when they're admitted to a nursing home and assisted living in a personal care home a lot of times they're admitted from those places from here they're in the hospital but better those places so if you better you see the stations every day you should be having a conversation while they're here because I take them to the nursing home the doctor only comes every 60 days and some people are better at than others and sometimes it get done and sometimes it doesn't get done and you want to do this as healthy outpatients as part of routine advanced ER you know part of your routine Agent P and we'll talk about this later you can actually get paid for it now so why not do it so this is always talked about who needs to participate for sure the patient I think sometimes we forget the patient I mean even though the ventilator a patient can shake their head yes or no but can right they can communicate so the patient needs to be part of it because even the patient with dementia I don't have a lot of patience with dementia they might not know where they are they might not know the exact day but they know they don't want a feeding tube they know they don't want to go to hospital again you know they can they're spitting out their food they don't you want to eat right so give us sins from the patie t have the page should be a part of it if they're not decisional then look and find it but have an advanced directive they might have actually already figured this out and told their grandson or told somebody so ask around figure out there have been famous Tourette's and and read advance directive and do what the advance director says adaptation show up for the nursing home one time and had a feeding tube and we'll ask you know we pretty much get the advance directive is when they're in the nursery now we're pretty good about that so I'm looking for Best Director and there's that box check that says he does not want to feed him - if you mean the top of the advanced directive it says if I have a terminal illness permanently unconscious or forgot the third things this is not what my wishes were this patient had in stage dementia he did have a terminal illness there's no cure for a dementia so people die of dementia so this advanced directive was applicable and he had a feeding tube and he took the bride she did not want a fee to do I'm like how does this guy have a fee to - so I asked the film am I mean I was nice of ask me what did you do in the hospital he wasn't eating so sudden he needed to he needed to be fed or he needed a tube or he would go peg and the blamers doesn't realize I'm an advanced directive it says to our social nutrition hydration or feeding they didn't connect the dots that this peg was this artificial feeding like no I'm explaining that for some bit you know so you know I don't remember exactly what happened I think what happened is um we just stopped using the peg you never wanted to be kept alive artificially with the feeding tube so we don't have to just yank it out you can take it out but we left it for a while I have taken mountain people in the nursing home do they start draining they get infected they're pulling on them so just know you should have really advanced to interpret it to the family make them understand what it says he's moving never told their family they even did one but if there is no advance directive then sometimes they did appoint someone to be a health care surrogate so ask around figure out who the healthcare surrogate is ask the healthcare surrogate if there's none of that if there's a if there's above them talk to the Guardian there's none of that been Kentucky law says next to Ken a spouse it makes the decisions then the adult children and is the majority of adult children over the age of 18 you don't have to go to the ends of the earth to find people don't want don't want to be found but the ones that are readily available you do have to make some effort but you know some people you just have never going to find all 12 kids parents then make the decision than other relatives and that's where it stops some states actually so people that would know the patient well like the landlord that they talk to every day and they talk they said with their wishes were but Kentucky doesn't go to landlords Kentucky stops at relatives cousins whatever some facilities law physicians to make decisions if you have two physicians for this non-beneficial treatment policy but each facility is a little different I think our Hospital has that policy for two physicians if there's a whole policy by the non-beneficial policy the physician of record needs to be a part of this I say I order one time in the hospital is said you know social worker discuss goals of care with the patient I'm the social worker can fill out the paperwork and kind of get it notarized and do all this stuff but the social worker can't tell a patient they're dying and they can't tell prognosis you know so don't shirk your responsibilities as a physician you should be having this conversation you should be telling the prognosis and then you know definitely other people move beyond that total but when you're having the discussion is family friends social workers nurses chaplains you know have your team there if you have 12 3 members I would come to know more than one person on the other side because you're going to be overwhelmed you know you need to have some other people with you when you're having this conversation especially if it's going to be tricky so this is Allison says this is how this is the technique to how to do it so don't just muddle through it actually use the technique try to do it in order practice it and the more you practice it the easier it gets so for before you having this conversation decide in your online like what's reasonable like what's going on what's the prognosis what's appropriate what's not appropriate find a quiet private place to meet I'll give this example what I mean when I was a resident at the VA I think I was maybe an intern and we had this patient that knew the goals of care conversation and the upper level resident I thought was God I thought did a great job having this conversation he actually talked to the family it was one of my you know or the few lessons actually talked to the family I thought it was beautiful now looking back on it we stood in the highway outside the patient's room and had this kind of important conversation so I encourage you not just in the hallway outside the patient's room and have this conversation it's really hard sometimes to find a quiet place to me a lot of times we're kicking the nurses out of their break rooms which is awful them now that hospitals are being renovated a lot of times they are putting quiet areas for meetings so find that quiet area the first question you always ask is what the patient knows so say for the family the patient tell me what you know about your illness you know where the surgeon stone rugby oncologist so what's your understanding of the situation and they'll be like you're the doctor you tell me he's like no you're the patient you tell me it's like I'm how about go back and forth you know it's like no no I do know everything I've already tried I know what's going on but I just want to hear in your own words like what is your understanding and that skips like half the conversation because sometimes if I'm dying I know I've been dying I've told my grandson where my stuff is and I've got my funeral arranged and I'm ready to go so then that kind of leads you down one path but some of them they're like oh I'm fine I just have some diabetes and you're thinking uh what about your colon cancer for a bit all this but they're like acting like they don't know that so they don't just kind of get you on the same page and also if you let the patients start talking first then they were keep talking it'll be a two-way conversation if you start talking first you will talk the whole time and they will not talk there'll be a lecture and you want to hear how they talk what words they use these high medical health literacy words that you can use high level words if they're very simple language you need to use very simple language so it's that's the first question and I do this a lot and I still miss that as still as Jim Pratt isn't telling what I think it's like no no ask them what they think what do they know then you kind of go over everything with them talk about prognosis talk about the millah condition fill in the blanks have questions and then this is how I kind of do it it's based on why isn't it's based on a lot of combination of things but there's four ways that you can treat people in medicine one way you can treat people is to cure them now so let's not hold my finger like we can do this sure really do we cure a lot of these diseases but sometimes we can so nobody go Bailey's cure eliminate disease but sometimes we can't we can't cure dementia but the following but their help we do rehab so the second goal is rehab you get them up you get a movie and you restore the function but you know sometimes you I can't do rehab they're so sick they're dying I mean you know I've had people a nursing home they come there for skilled care rehab they are dying and then like those poor people get up and walk I'm like just but know that we had to going for rehab Utah well nowadays we figure out we've been scoping for for other things we can spell them for end-of-life care thank goodness but um but some people just can't do rehab they're too weak they're too tired or they're too demented they can't follow directions but can't remember they're taught yesterday they're fighting you won't even touch them but you can try we have sometimes you have the trial just to see is it going to work or not and after rehab the third way we treat people is life prolonging palliative care where we do stuff to keep people alive among the living areas we do dialysis or do blood transfusions or do antibiotics we do chemo it's fine it's good it's fine whatever they want and that's usually if someone is not ready to die they haven't got their affairs in order it's a young mom who's going to take care of my kids and I die I've got a wedding next week you know I've got things to do all that unfinished business so you do so if you give them a blood transfusion get into the wedding get them to the next event Bobby our patients have say you know mom I'm graduate let my kids are my kids are married I've lived with the laws I'm 80 years old I'm ready to go I don't want to suffer anymore so so it's okay you know you kind of have to have that conversation because sometimes it's hard for them to figure out the difference between the number three and number four now just ask them is there unfinished business is the things that you need to attend to if slowly we should do life prolonging if not then the fourth way we treat people is comfort focused palliative care when you don't anything prolong their life you vote in a shortened life you just kind of let nature take its course and you very aggressively treat their pain and symptoms and people think I can further through this that could change their mind but it's good just kind of a sense about what we're trying to do and then once they tell you what the birds you tell them what that means you know you don't ask them do want antibiotics do on two feeds do it like a smorgasbord you just put what you want so I go no you're the doctor you find out what their goals are their values are how they want to live their life what their little hard what their life things are going on and then once you figure out that with them what their goals are then you can kind of fill in the blanks so you know after you could talk about the girls you talk as lots of questions develop a plan I would encourage you not to say anything about we're going to us draw care you know who wants or Thrall care I mean we don't want straw here we always care for patients the question is do you want to say positive things you know what we I'm going to do so do you want curative care a comfort care where someone treats you either way all those treatments are Val valuable and valid so doctor the discussion that has happened had a president student have an hour-long conversation I'd go document it and it's had two sentences I'm like so you know who is there those present and then but what happens that wouldn't document thing because I still feel code or there's nothing's changed I'm like even that's it's changed you plan to see if you have a discussion then the next doctor coming around behind you can see what happened and follow up on that discussion so document who is there and I would encourage you to say the names the people that were there forgot your Murphy I use it as all the time but I remove my letters discharge summaries as discussed with the family you know girls who care a comfort so then I'm attending Nixon's patients in the hospital I'm like I walk into the family all I know girls or comfort we're gonna do this right who sleep those recovering my sister said that I think this what come to find out there's like 12 kids like 37 said the girls were comfortable 806 didn't say that you know so who actually was there you know whatever names not the daughter well there's five daughters you know so and you had to talk with the rest of the team this is what I made a big mistake to I've made all of this stuff but on I memorized the nursing home and this is when I had little kids and the daycare closes at 6:00 you got to get your kids by 6 all right you put $5.00 a minute afterwards order so I've had the whole conversation took a man which is fine these conversations usually take about an hour if you're good maybe we can do the rest but don't go over an hour because you're just rehashing the same thing over and over and no one's assigned anything but I didn't have a lot of time to document so I did document I don't but have a lot of time to talk with the rest so like Elaine have a nursing home within a great card to the ministry here's our office we have to have a big I got in trouble but as well because basically the nurses were not on the same page and they're like doctor firm is trying to kill off people you know what is she doing guarding right in his doing hospitalized do you know comfort measures I only start the other bites this patients fine firefights so in the nursing home there was like the best patient at the motion over those who quit like we're in a Minnesota they're not doing she booth they're amazing but I think people lose perspective and on the outside looking this patient they look fine but I can the inside but I can say they've got dementia all the stuff but note that the noses aren't like leaving the medical records from front to back so you have to talk with your team because the nurses are not going to write you like for the morphine they're not going to give them morphine if they don't understand what's going on so if you can't do it call back on the phone make sure everybody's on the same page and what I figure that from that experience is I don't have those conversations that the nurse with me I just bring the nurse right in with me we do it together or the chaplain or somebody from the system that you're working then they could kind of be there and validate everything so this is where I start talking about this most well I want to explain this there's two types of advanced care planning one is the traditional everybody knows about Kentucky pass a law that we have advanced directives advanced directives living there's a big thing called advanced directives there's two parts of it you're living row and you're healthcare surrogate we've been doing that since forever since the 80s I think it's where that law was passed but now we have a new thing called a most form and the most form is this and if you don't have it let me know we'll pass someone out but these are actionable medical orders which are direct this is an order set the living war is a document that we hope that someone looks in the lead but this is an actual order set in other places it's based on this post paradigm other places it's called post physicians orders for sustainable treatment or most or most in Kentucky it's called most medical orders for scope of treatment and so we're going to go over all the details of it but the purpose of most is to provide a mechanism to communicate the patient's preferences for end-of-life treatment across treatment settings so we'll take this piece of paper wherever you go to the emergency room to a nursing home to the dialysis center to the chemo infusion center like everybody knows where it is you put above your bed on the refrigerator and this is you know this is an order set and these orders should be followed because I was happened to me in the nursing home I hope it's a long conversation out document the whole thing on a progress note I'd write orders you know DNR you're not hospitalized and then nothing happened for like six months right well then by that time but the notes are saying their medical records the medical records close at five I'm there at six this person's crashing and I'm thinking I think maybe six months ago well can't really remember the details of what they decided I mean I wouldn't do you know I won't do not hospital but today what antibiotics or not you know they want to go the hospital I can't remember they change your mind who decided all this and I can't find without convention it's the same and it's it's not there's no scanning there's no electronic medica record it's thin it's a medical records medical records it's locked so this it shows up in the child that's why it's a bright pink it's in the plastic part and you can find it so we're going to go over where you can find an electronic medical record so I'll just white girl if you can pull this out I'll explain it to you the section area is pretty much like and it's it's pretty much like what you've seen on the dance directive is it at Andrews has resuscitation or do not attempt resuscitation or about natural death section that is a new section you know this is not on their living will do you want first local treatment which includes intensive care you know for treatment life support transfer the hospital you want limited additional interventions which is transferred the hospice indicated but of more intensive care and that's basic medical treatments do you want comfort measures which is do not transfer the hospital and keep you comfortable clean warm dry clean and we can write other instructions there and when section C is antibiotics or not do you want antibiotics or not or you can say I want antibiotics for trial that's a that's not in the living room section D is in their living will the left-hand side is IV fluids the right-hand side is feeding tubes and the section II is who did you talk to about it from this part is patient has an advanced medical directive such as the living will or healthcare power of attorney I certified this form is in accordance with the decisions in the current advanced directive I will testify in Kentucky in this you know State Legislature the house and the Senate committees about this and I tell you these House and Senate communities very very hung up on this because people have an advanced directive already and does this going to supersede it or not or what cause they're based of you do yourself personally and that's the only person that can do it so that's why we can't go to I'm so demented they can't do their own advanced directive if it gets too far gone and they can't make their own decisions there is no if it's directed to be done but this most form anybody can do it and healthcare so the patient can do it but the healthcare circum can do it so the legislators didn't want a healthcare surrogate coming around after the patient or they decided one thing and changing it like killed that off and get his money or something so that's not what we're gonna do but that's what they were worried about so you have to certify so if this does not match what the living will is I would recommend you just don't do anything or call the Rapids Community College palliative care consult figure it gets complicated but I'm only half the physician has to sign this we're Tyler but medical orders for scope of treatment because if the thought was like physician assistants or nurse practitioners could sign it but the legislature is going to have none of that only a doctor can sign this so in rural areas sometimes there is no doctor to be found for like a hundred mile vengeance or something it's all nurse practitioners but they're gonna have to get this to a doctor to sign it to make it legit and make it legal this is a legal document now I explained the history of it a little bit but I just want to tell you a little bit more about the difference and also in the back if you read it it tells you um you have to write a progress note when this was done so I've told them that was info and I are working listen we've hit the practice that's to remember all the rules and she cut another progress note but I think what do they want in this progress notes are a little bit more clearly the Randolph progress note explain like how did this come to be like how do they decide these things it's not about that I've chf'er COPD or anything it's like how did this come to be so you don't just go around light and Dean art on everybody without like a progress note to go with it explain it so you can see the difference here in advanced directive you know it's for all adults the most fun they're really recommend you do this if someone has less than a year to live yeah anybody can do it any time but just know when you do this form and fill it out this is an order so it takes effect immediately today like if you show up in the ER this is what they're going to do so um it's people with more serious illness and then advanced directives for the future you know if I become permanently conscious yes like in the future that the most is right now like I said who does it I already talked about that and what things directive it says any sudden like a little a lot of lawyers drooping directors my husband silver I love lawyers but really this is not the lawyers job like we should be doing this you know because the lawyer puts in a lockbox is all the other important papers and no one has access to it we would like this to be like on the refrigerator so so really there's really a medical setting but I would say the most form can be still done in any setting the doctor has to sign it that's the big deal so whoever fills it out that's great but take it to the doctor to sign it to make it legal and then the third the resulting product was a surrogate appointment and statement of preferences and the Morrises medical orders based on shared decision-making we talked about who can do this the portability of the advanced directive is hard it's the patient the family that's responsible for going to get the other lockbox or whatever but the most form is our responsibility like when we service on the hospital we make sure this goes with them to the nursing home the nursing home make sure this goes with them to the dialysis to make sure it goes through to the oncology doctor's office so it's a healthcare responsibility and then we have to review it so and they recommend you review it every year the kind of photos is only for people that have less than a year to live so they probably will be alive in a year but there might be if they are you have to update this every year and you update it whenever there's a change in condition so a good question is like how do you know somewhere like how do you know make it this form for that it's a surprise questions you know would you be surprised if this patient dies in the next year maybe I could see that happening well then throw out the filament look at look for the five years who knows you never know but if he's would be surprised if they die in the next year then you should do it and I hate to say this that uses CDC for a lot at the VA I haven't been there in a while they used to be like I think almost half the people in VA I wouldn't be surprised so we'll go ahead and just throw out the form and the VA has is I think the theory calls in most veterans I did you to see a most formative VA they have and I know they're part of our most coalition I'm not sure I know though you have to you know each third has a different form there are these veterans you know it's a travel across state lines and same thing when you're traveling right here at Kentucky Indiana when people go back and forth Indiana has one of these you need to fill out Indiana's both you know both some if you have a patient's going back and forth so the benefits of NARAS that establishes the page decisions and that patient is able to have the decisions honored and improves that hCAP raters improves quality increases staff comfort with these difficult conversations like that renal attending that caught me in that dot in the doctors parking lot like he didn't know what to do he knew he doesn't do exactly what he should be doing but he didn't know what else to do but just just inspect the boxes it survives because I was having these conversations in the nursing home I had done research 91m have you got antibiotics of people every dime these are called pneumonia the old man's friend like it was okay to die of pneumonia you have people morphine and give them oxygen again brilliant treatment you're still treating the pneumonia but you don't have the treatment for cure you're treating it for comfort but people look at me like I'm crazy that you don't have to have antibiotics I'm like yeah they don't swallow the pill you know the time down to give them the IV like it's okay not to give antibiotics and I thought that I was just making about basic now it's in flight or pink and black it's on the piece of paper like it's for real you know so it's nice to have it you just it helps the staff it helps you all helps everybody a DES decrease lengths to stay it decreases hospital readmissions and now we can bill for it advance care planning codes and I'm going to go over that just in general most in Kentucky it's like everything else Kentucky's a little behind this times that organs have this for years and years and years but Kentucky socialism hospice and palliative care spearheaded this as a pilot project in 2010 at the nursing homes and it took us three years to pass this legislation and governor Beshear signed it into legislation in March of 2015 but it's in-house by the Kentucky Board of Medical licensure like they're in charge of this form and it took them about a year to kind of come up with the rules around it and they put on their website in November 2015 and so really it's only been since 2015 the end of 2015 that this has happened so in 2017 in January we started the statewide Mo's coalition to kind of get this out there get people to understand it and so now we're using it in nursing homes Norton's using it Baptists Amy's Owensboro Nazareth a lot of people are using this form you and you are not overusing this form so we're trying to get everybody to start using this so you can for coalition this is the action if you go to this website at the top here you actually go to our website but we're trying to make it a little bit easier and we still have to finalize that and I'm sorry it's taking a little longer than we wanted but the Kentucky most coalition it's a statewide stakeholder group that's the actual law there that processes law so it's nice because when I first started up nursing home I was using advanced directives just a regular living roles I was writing orders do not hospital I was no anabolics all the stuff all the stuff and I wanted to start using this organ was usually at Lester's use a lot of nursing home they love their lawyer right now like a 20-page letter where I could not use this form because I was supposed to be using the advanced directives which was Kentucky law and this was not Kentucky law so now I'm gonna find that lawyer and tell if it's Kentucky law now we can use this form is legit we got a you know got it's it's okay so the most coalition I said bad we've had over 100 members in about 15 counties the goal is to have every county represented we've gone to Hazzard we've gone to st. Elizabeth's we've gone to Owensboro and we have nurses physicians we want to add chaplains and patients so if you all about to be part of the most coalition it's we have every other month calls you can call and you can come face-to-face and we have a sign-up sheet that's going around and also back on the table you can sign up so you can see across the country this is really exciting because this was January 2018 just a few years ago but there's a lot of thirds that have nothing but some of the mature programs it used to be Oregon now Oregon is now separated for the National Post organization due to operational differences they're kind of doing their own thing but still they're very mature for have an Oregon start with others but also California in West Virginia and I thought the first Virginia can do those who become a mature form Kentucky can do those in the coming winter program but we're currently developing program so we're getting there we're getting it so we want to have a system champion to make this successful we want staff who understand and have comfort discussing it because really knows can discuss this a social worker anybody can discuss it chaplains one had policies and procedures so we've been meeting with ULP with admitting with you in the hospital we now do have policies and procedures we just have to get the IT part to make it happen we do have support from EMS EMS has a video on their EMS website they'll show at the end that they've told other EMS people look for this above the bed and on the refrigerator this does replace the DNR for EMS so use the DNR for EMS you can use both but this this they know they recognize we might have a monitoring product process are called improvement process we have to have position involvement cuz positions have to sign it you know so if you know if someone asks you to sign this please sign it at least have a conversation rather you have to do a progress note to go with it we have to have workflow and we're meeting with you up here again on Tuesday and European you eval are now health system so we can help the same process in both places and I'm not going to go through this whole workflow but this is if you have a life expectancy of greater than one year and this if you have a life expectancy of less than one year you can see right here however the workflow is to complete the most form so so this does improve quality measures so the big thing about the advanced directives to be able to document it story and can retrieve it and this is the good problem I'm going to show you this so in all scripts there is a ribbon where you have the patient's name date of birth they're just added this over here they'll change it a little bit and I don't know if you've noticed probably you don't see that much because you don't feel it there but you put in there you're the same directives living well and I'll show you how to put it in there you click on the I button the I button tells the patient's phone number address Nixa can click on that I button the information button and this will open the patient profile dialog window so I'll show you push on that eye button you get this screen you get the picture it's not Wonder Woman but it is a picture a person around right here sometimes you have to scroll up here make sure it's at the top because this is at the top and then you click right here that says directives and you can clip do they have an advanced directive yes or no and if someone actually is I do not resuscitate like they fill this out no matter what their DNR then I have included their DNR you can write an order do not order in the outpatient medical record if they have a living world click 'add they if that's all I click so that's the things as you click but sometimes I want a little bit more detail because whatever you click there is going to show up in the top right of the banner up there but sometimes I'm going to know about more so I'll do an ad alert which when you're do an ad alert if you um and at alert like growing here has like a little red vein that you'll sometimes see like allergies listed there when their last PQRS was or whatever you want to put in their dialysis patient whatever so if you do an alert or short then I'll say you know if reversible full code if irreversible DNR some people have told me that like if I can if I can say listen if I can't let me go well so it's irreversible let me go so I'll put that up there and also see for 18:18 note they're not remove either progress note to go with it then the person can find the note and read the whole note and figure out what's going on so then you always save encloses so it's saved and then they add alert I told you about that and then actually find these advanced registry gets scanned in the EHR you when you're on that chart viewer screen and you see how your progress notes and stuff I don't use this button I don't have I looked at my I don't have this button but I had this button is pressed - it collapses and it expands the chart viewer and if you collapse that will give you these categories and one of the categories is administrative it's always at the very very very very bottom if you're scrolling through all of it to the very bottom and on the administer that it has advanced directives now you might not see it you just don't have advanced directives in the chart but they have instructors in the chart that are scanned it will say living world power of attorney and it will be in there and heir advance directive their most form everything will be scanned right there so no I'm not as I mean I do work in Cerner but I don't do it but once a month and so I'm not as good so BG help me with this but if you want to add a not a document in there but advanced directives you go to documentation go to add and then dynamic documentation and then you can choose all and it says acute dose page but you can type that in there and say like most form and then you can write a progress note to kind of go with it that way you could find it under advanced directive because it'll say advanced directive live in real you can pick that category and you can free text as the thought is that we could do like a most form template and have it in there as part of the free text documents like you have your agent P's and things but this is so crazy to find an advance directive scanned in a Cerner it's like about 20 steps so I mean that's the whole problem is that it's too complicated what one click one click is it better so we're working with IT to kind of fix that if you have any ideas please let me know the big thing is to educate everybody you know time so this is looking at you I saw you in the audience so you know everybody not just physicians the hospital everybody in the hospital everybody outpatient setting all the nursing homes need to be educated it's funny we were doing this as part of a grant and I was doing this with one of our family medicine residents who's now no I know she wasn't here she was in medical school here residency away she was in Velasco and I was a go came like me to meet with she was doing this in her nursing hot to meet with all the hospitals make sure they have this because you know when you send people from the nursing home the hospital the emergency room needs to know that this form she like Christian I got it covered my husband's the ER doctor there's like one Hospital there's like four nursing home in Glasgow she's the other terms that I've talked to him tonight he'll recognize this 4,000,000 nursing homes we had to talk to everybody but it does make it easier being in a smaller town so you have to have champions I want to just tell you about these codes because you know why do all this work and not you you know like I said my husband's attorney that they paid for every eight hours eight minutes eight minute intervals like every letter they write every phone call they bill for it so we can go for this now so nine nine four nine seven is the first 30 minutes which is actually 16 to 45 minutes if you spend 20 minutes if you spend 16 minutes you should go for it and then if you spend more time you spend an hour you can build you can add on both codes it has to be face to face with the patient but not just the patient in the passo is only the patient now you can go if you're just talking to the daughter or a family member or surrogate and not just the doctors can bill the nurse practitioners can bill and licensed clinical social workers anybody that can bill Medicare this is a Medicare code non physician practitioner I just want to show this article which kind of talking of beginning like what the research is on where people die and how they die but all of them like a sudden some doing this for a long time they've had education they've had two kids have hosted conferences a coordinators that they have a statewide registry there's a great video if you wrote a post website where EMS calls a state ride registry and says well I'm seeing this patient call nine one Rhonda call the state registry no tell them what the most forms and they know what to do it I'm took him to the hospital because they were doing a house for us lots of stuff industry there was no industry funding but a lot of support and an Oregon versus United States died at home or at 66% of people died home just like by over but she died at home and whites that's 39% people died help don't forget the researcher but 80% people wanted at home so it has been close but we're not as close no she shouldn't research on Kentucky I don't think anybody's done that and we'll honesty you or Oregon on the 18% when I see you in the last 30 days and the US twenty eight percent when the I see you home the last 30 days or than seventy three percent were at home in the u.s. 54 percent in Oregon so the two fields did not extend life and there's low rates of to fit in Oregon versus United States the rest of United States so it works so my whole point from to all this it actually shows outcomes it will work oh just know that the form is not the main thing the goal is to have this conversation and most doesn't replace an advanced directive because the advanced directives for the future the most is for to those who need both and please don't rule because you know Medicare houses code they're not gonna breath so if nobody uses the code let you say what the code go and we'll be able to bill for it so you can use it or lose it and you have to have a whole broad-based approach so please be part of our approach this is lots of resource post website all this post stuff wwp org is like the big coalition has a lot of good information here's a most coalition when it gets up and running he'll be KY most and then this is the PRS the actual law or Kentucky Board of medical license your website has it on there and this EMS idiot videos great it shows an EMS totally get some useful a video out about it the conversation projects good there's lots of things and this is our contact and justice contact you can sign the most coalition website I mean the Sun up sheet and there's lots of good references so I know we're running a little bit late but I could take maybe a question or two yeah second so if you don't mind translation is how you open a dialogue or your sketch of the site and state-o marketing or end-stage COPD or or on Halloween change information of provinces with a patient of Emily and progress and step in question and edge which is 9.5 this capture manage communication how many intensity yes so how do you have this commerce and you start the conversation sometimes you know but just blindside someone like today's the day so a lot of times if you know like in your mind you kind of a sense this person's been back and forth the hospital every month they're not getting better or they just never get your judgment fractionate m % a little quotes here you know everybody knows they're Oregon you couldn't have a lot of research about when people are gonna die if you don't think this person the surprise question you wouldn't be surprised if this person dollars in the next year didn't you think in my mind okay I need to have this conversation right so what I would do and the patient comes to their 5:00 appointment say hey listen I think we need to have the conversation about goals of care not about die just about goals in care cannot have you come back tomorrow or next week and bring your family bring your health care surrogate and we're just gonna sit down and I always make it positive it's not like you know I just want to be prepared and I hope for the best prepare for the worst we be covered either way you know just to kind of do advance care planning it just normalize it you can say Medicare has this new code you're entitled to it as part of your Medicare benefit I want to give you all that you're entitled to you pay for it you might as well use it it's free and so our Medicare allows us to do those you can say I'm have to because Medicare told me to you know Medicare just let me on Medicare that you don't know more things you can give them good things Medicare can do good things whatever you want to say you know you know what the patient will respond to and then make an appointment that's what the appointments for is to do advanced care planning but sometimes people never come for that appointment so if you find that that's one of those kind of people you have to kind of sneak it in so if you just so today I gonna talk about their blood pressure too much I mean maybe a little bit but really I'm going to focus today on advanced care planning and just kind of cut everything else short and just do it it you know it does sometimes take an hour but if you know the patient and stuff it doesn't take sometimes an hour or you can kind of start the conversation give them a copy in advance I have copies of advanced directives in my office I have copies of those forms in my office print out some type the pile on the rollout and just came to him and said we'll come back next time and talk about this you know so that's one thing just had to do it you got practice it because there's no exact one way everybody has a different technique and learn how to make this better across the whole state of Kentucky if for the most coalition we haven't we have cars every other month and we need everybody to help make this happen because people come from all over the state and they're going to come here it'll be nice they come with the most form and we'll be done you know be nice to show up in your office from their primary care doctor with the most form in all states around Kentucky have this so you call me you have my website you have a try because it work call me and we'll talk about how to make it better yeah we're meeting Tuesday we met with this nut wah MD and there are all kinds of companies out there their time there was you then we wrote it they would comp so Medicare bolts at their bits of billing code so now you can get paid for it and everyone wants to get paid for it so a meeting with this company in that law indeed that has it out and happen all this so we're trying to it's not for free so we're trying to get you about how our healthcare system you know does it call you know near the house we're going to have a house stuff maybe buy into it but not yet but um so you do know that you're gonna be like your snowboarder and you go back and forth and floating I recommend you do both one for Kentucky one for Florida go home happen so you don't have not talked about those ethically there's a bit in those later right first if someone shows up at someone showed up in my nursing home which has happened from Florida with the most reliable ozpaula I'm just gonna do with this nose form says I still call the family mature so it depends on the doctor right which if you show up in the ER in Florida versus if Kentucky moves from the doctors the kids say I'm not going to I don't like it look at this now ethically they should look at it they should do it it says but legally they're freaking out whatever legally it's not legal in other states every state has their own most form and you have to have the state that you live in to do it but I recommend you consult like you can set the ethics committee this Irvine's never been a perfect situation of forms that can take care of everything get the healthcare surrogate involved with the right people involved talk to people dialogue document you can always you know make exceptions but this is really a legal form that says and that's why that's why you make sure when you sue the doctor you have to sign this form you want to make sure everybody understands this won't like you listen no matter what happens we follow this form so they don't agree with that then perform or I've had this happen the nursing home this patient was just there for me we had like five and shoot down there do not go the hospital no antibiotics I'm like listen if this gets infected you need antibiotics I'm not going to find that for you know so you have to have a conversation it's not the format you're right it could get tricky and just I put the right people involved to help you and I try not to fight about it it's a discussion then we can be common people about it do not call the lawyers call the lawyers really about this you know encouraging me here to have these very mutual foundation yeah and let's they play on and the best panels and all this stuff yeah yeah that's what you don't study yeah I know oh yeah yeah yeah I will tell you I think our countries come a long way like you know Medicare is actually paying for this now so Medicare you know we figured out that it's better to do this ahead of time right in the crisis situation and there's this conversation project there's a lot of things out there about it they're kind of it's more normalized like you have a jewelry party of a Tupperware party you have our bowls of care of discussion party you know these kitchen table conversation projects and stuff you're right it's complicated and so that's for also to answer your question everybody's been trained in this so like cardiologists part of the fellowship you can do anything for the part but in the heart door what do you do you need to know how to have these conversations we know you do only been like the kidney but when the kidney fill what do you know you don't know havoc have these conversations and they screw it up so I recommend that everybody votes have been part of here get online there's lots of good education things every fellow needs to have a rotation in this because it's gonna happen and we want to do it right the first time and not cause big because they'll try to do a little thing would move at the house in the Senate were fighting about it imagine yeah yeah we should do that but you know if we won't look at Lubert I think that would be the next step for Kentucky oh yeah that's right yeah just do one for each state that you're and that's the best thing you know if you really are trying to avoid all these problems then 100 percent legal 100 percent best thing is do a form for Indiana and Kentucky you can do it we have the formula on line just do it if you can do it get a good yeah yeah you just need to have a good conversation who should we should oh the whole thing is we should always honor the patient's wishes is not really the family's wishes is what the patient would say if they could speak for themselves so it's complicated and we can have some conversations offline but we have the rules and there's always exceptions but yeah thank you guys so much and then come up if you have other questions and laughs [Applause]