Conversations about end-of-life are often uncomfortable for patients, their loved ones and often, even the patient's healthcare team. Therefore, too often, the conversation is avoided resulting in confusion, fear, sustained grief, guilt, and misunderstandings, which may weigh heavily on all involved for an extended period.
These challenges may be avoided or at least significantly reduced by a thoughtful, sensitive conversation. There are many ways to begin the conversation, but the objective is to have the patient and/or their loved ones understand:
Why the POLST is being considered;
What each of the choices on the POLST form involves, and;
What the choices mean for the patient's longevity and quality of life medically and in terms of the patient's values and goals of life.
How to Begin the Conversation
POLST should be considered if their healthcare provider would not be surprised should they die within a year. That means, the patient has co-morbidities, is elderly and very frail (see our frailty assessment) or nearing the end of a life-limiting illness. We can suggest a few ways to open the conversation. First, prior to the meeting, review the patient's medical record. Note medical transfers, changes in health status, etc. Sit with the patient, then you might begin by asking one or a few of the following:
"Tell me how you feel about your health in the last X months" (where X is a time-frame that reflects a significant decline, several interventions or medical transfers).
"I understand that you've been to the hospital several times lately, how do you feel about that?"
"Do feel like your health has been improving or declining over the last X months" (where X is a time-frame that reflects a significant decline, several interventions or medical transfers).
I'd like to talk to you about something other than your health...tell me what is important to you at this stage of your life?"
These questions help the patient or their loved ones get "on the same page" as their medical team. The last question will tell you about goals that may not be reflected in the patient's medical record...perhaps they want to be able to see a grandchild be born or graduate; or, they want to be able to enjoy the taste of food, or be able to visit with their loved ones...all of these will be impacted by the POLST choices they make, so it is important to address their ability to attain these goals.
An Informed Consent
The patient (or the person completing the POLST for the patient) should understand what:
the choices involve;
the alternatives are;
the risks and benefits are; and,
the likely odds of success or failure.
This means, for example, an explanation of what CPR involves (ICU, intubation, inability to speak), what artificial nutrition and hydration is (it is not Ensure) ...it is nutrients via a tube through the nose or a hole and port in the stomach; what treatments will or will not be provided with Comfort Focused Treatment; or what, in their instance, may be provided with Selective Treatment.
CMS (Medicare) now reimburses physicians, APRNs and PAs for Advance Care Planning (ACP) with their patients. Because patients may be in various settings, “these codes will be separately payable to the billing physician or practitioner in both facility and non-facility settings and are not limited to particular physician specialties”. ACP may be added as a voluntary, separately payable element of the AWV [Annual Wellness Visit]. CMS instructs that “when ACP is furnished as an optional element of AWV as part of the same visit with the same date of service, CPT codes 99497 and 99498 should be reported and will be payable in full in addition to payment that is made for the AWV under HCPCS code G0438 or G0439".
The following two codes may be applied:
Code 99497 - provides for a 30-minute conversation with a patient, their family or their surrogate decision-maker.
Code 99498 - an add-on code providing for an additional 30-minute conversation.
You may find the following helpful to your or your patients: