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The Surprise Question and Five Wishes: Best Care Possible

Learn about the surprise question and its impact on advance care planning. Explore the importance of discussing goals of care, palliative care, hospice, ethics, and spiritual care. Discover how to achieve the best care possible.

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The Surprise Question and Five Wishes: Best Care Possible

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  1. Oct, 2018 The Surprise Question and Five Wishes: Update October 2018 Laurie Jackson Masters of Divinity Masters Certificate in Clinical Ethics SENIOR DIRECTOR Virginia Mason Memorial’s Care Line for Advancing Illness Home Health & Hospice | Palliative Care | Bereavement | Ethics Advance Care Planning | Spiritual Care

  2. The surprise Question What’s Our Goal? BEST CARE POSSIBLE What hinders us? • Uncertain What “Best Care” Looks Like • Cure Versus Care, “Treatment” • Assumptions • Time • Uncomfortable conversations • Rarely is it bad intent

  3. The Surprise Question in Yakima • 2015:Dr. Mimi Pattison in Yakima at Circle of Life Symposium • 201610-month adventure to add to hospital electronic admission set • Created Inpatient Navigation Team • Leader/Administration Buy-In • Physician Education • In Midst of Virginia Mason/Memorial Affiliation • 2017: Haiti Road to New Jersey Road • Clinical Trial Began • Physician Education/Behavior Modification • New Angle to Education: Teamwork • 2018: Beginning Work in Clinics

  4. The Surprise Question December 21, 2016: Surprise Question Initiated First Hospital to Standardize Every Patient Admission Every Floor Every Physician Electronically Asked and Answered

  5. The Surprise Question How It Works • Physician Responds to Admission Queries Diagnosis, Code Status, etc. • Then, HARD STOP: Would you be surprised if this patient died in the next six months?

  6. The Surprise Question

  7. The Surprise Question How It Works Would you be surprised if this patient died in the next six months? • If Physician Replies YES: Physician Able to Continue with Admission • If Physician Replies NO: Electronic Order Sent to Navigation Team for Consult Physician asked if Palliative Care or Hospice has been ordered Physician Then Able to Continue with Admission

  8. The Surprise Question First Physician That Answered NO • Orthopedic Surgeon Who Replaced a Knee • Did we do the education incorrectly? What We Learned From This

  9. The Surprise Question What We Learned in First Months 2/3 of physicians always answered YES Lessons Learned: (come to presentation) Time to Bust Some Myths

  10. The Surprise Question Total Surprise Questions Answered Jan-Mar, 2017: Over 5,500 Total Number of Admissions Jan-Mar, 2017: Just Under 3,500 Something’s Wrong.

  11. The Surprise Question Turns Out…Another lesson learned (you’ll have to attend the seminar to learn the lesson)

  12. The Surprise Question Example Admissions – Answers: January, 2016 Patient First Answer: YES Last Answer: NO Most Common Answer: YES (5/9) Patient Died Within 6 Months

  13. The Surprise Question Example Admissions – Answers: April, 2016 Patient First Answer: YES Last Answer: NO Most Common Answer: NO (6/8) Patient Died Within 6 Months (was transferred to hospice and died within one week)

  14. The Surprise Question ALSO TO NOTE: • We have to wait six months after a patient’s admission to determine if the physician was correct in assessment of patient’s prognosis • Started January, 2017 • January Admissions: must wait until August, 2017, to assess

  15. The Surprise Question ALSO… • Death Records are Published Quarterly (after March 31, June 30, September 30, Dec 31) However…for patients that have been in the hospital and die within 6 months, how many are dying before the 6-month mark? Could we get a taste of accuracy with the data we have?

  16. The Surprise Question TURNS OUT WE CAN ASSESS ACCURACY. WHY?? Of All Patients That Died in the First Six Months After Admission… 2016 Mortality Post-Admit 2015 Mortality Post-Admit 1st 30 days: 61.63% of deaths 60 days: 74.55% of deaths 90 days: 81.86% of deaths 120 days: 88.03% of deaths 1st 30 days: 59.75% of deaths 60 days: 75.51% of deaths 90 days: 83.94% of deaths 120 days: 90.40% of deaths Based on death data through 6/30/2017

  17. The Surprise Question Quarter 1: Jan, 2017 – Mar, 2017

  18. The Surprise Question Quarter 2: April, 2017 – June, 2017

  19. The Surprise Question Quarter 3: July, 2017 – September, 2017

  20. The Surprise Question Quarter 4: October, 2017 – December, 2017 Data not confirmed—need 6 months death state death data

  21. Physician Group/Department level – all answers were used for these calculations, not just one per patient, and not just the ones that were ordered and entered by the same person.   As before, I left the Oncologists in, even though the numbers are too small to show anything significant.  The rest have at least 150 answers. Physician Data Per Specialty

  22. Another Initiative: advance care planning Changing the Game

  23. Another Initiative: advance care planning Diagnosis Death Non-Medical Model Medical Model Palliative Care Chronic and Curative Care Hospice Bereavement 18 years and over Advance Care Planning Memorial Home Care Services/Compass Care 574-3600

  24. Five wishes in Yakima: Some statistics • 70% of individuals would wish to die at home • 82% say it is important to have EOL wishes in writing • 80% say that if seriously ill they would want to talk with their doctor about EOL care • 70% of people die in a SNF, hospital, or LTC facility • 23% have ever written their EOL wishes •7% report having an end of life conversation with their doctor • 8.8x increased likelihood of prolonged grief if loved one dies in ICU vs hospice • 5x increased likelihood of PTSD if loved one dies in ICU vs. hospice • 10 more days spent in the hospital in the last 2 years of life when the patient does not participate in advance care planning Stats thanks to Honoring Choices PNW and Californian Healthcare Foundation

  25. Five wishes in Yakima: Some statistics Why are we using FIVE WISHES? Valid in 42 States Customizable Addresses Biggest Fears Cost-Effective User-Friendly Not a Do Not Attempt Resuscitation Order in the Home We Have Trained Facilitators To Go To Community Groups, Homes, Churches, Hospital, Clinics for Five Wishes Parties We Have Distributed Over 70,000 Five Wishes In Our Community Memorial Foundation Pays for Five Wishes for Yakima Stats thanks to Honoring Choices PNW and Californian Healthcare Foundation

  26. Nearly 2 years into Surprise Question, What we are learning: • Not all physicians understanding difference between advance directives and POLST • Hospital/Clinic Physicians benefit from team members knowing • Decision-making order • How to provide difficult conversations • Objective methods for providing best care possible for patients with advancing illness and end-of-life concerns • We still have work to do • Surprise Question is a key element to providing great medical care and getting patients onto extra levels of care Stats thanks to Honoring Choices PNW and Californian Healthcare Foundation

  27. Questions? Thank you!! Stats thanks to Honoring Choices PNW and Californian Healthcare Foundation

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