Policy Action Plan: Resolving Conflicts over Life- Sustaining Treatment in Virginia Dea Mahanes, MSN, RN, CCNS, FNCS NURS638 Health Policy, Leadership & Advocacy Virginia Commonwealth University
Learning Objectives • Understand the current state of policy action in Virginia pertaining to conflict between patients/surrogates and clinicians over life-sustaining treatment (LST). • Apply environmental scanning principles to evaluate the barriers and supports for LST policy action. • Analyze the impact of the Joint Commission Health Care Decision Matrix for 2018 on LST policy action.
Health Policy Issue Introduction • Life-sustaining treatment (LST), also referred to as life-sustaining care: mechanical/artificial means to sustain, restore or replace a spontaneous vital function (paraphrased from the Va. Code Ann. § 54.1-2990, 2009) • Conflict over life-sustaining treatment is common (Pope & Kemmerling, 2016) – Can cause moral distress (Whitehead, Herbertson, Hamric, Epstein, & Fisher, 2015; Hamric & Epstein, 2017)
Ethical Implications • Autonomy – Supports patient/surrogate ability to make decisions about care • Beneficence – Obligated to provide interventions that will help • Non-maleficence – Ethical responsibility to avoid harm • Justice – Costs of care, fairness/non-discrimination
Health Policy Issue Introduction • Code of Virginia, § 54.1-2990 (2009) – Clinicians are not obligated to provide treatment that is medically or ethically inappropriate – Care must be continued for a period of 14 days to enable the patient’s agent to seek transfer to another provider or facility – Does not address actions to be taken at the end of the 14-day period if no provider or facility has been located
Health Policy Issue Introduction • Virginia Joint Commission on Health Care: Life- Sustaining Treatment Work Group (Mitchell, 2017) – Survey of health systems in Virginia – Drafted language for proposed amendment
Health Policy Issue Introduction: Draft Amendment (Mitchell, 2017) • Allows for cessation of medically or ethically inappropriate treatments after 14 days – Special considerations for artificial hydration and nutrition • Requires hospitals to enact policies that outline actions to be taken in the event of treatment conflict – Second medical opinion – Interdisciplinary medical review committee with opportunity for the patient/surrogate to participate – Inclusion of decision (with explanation) in medical record
Health Policy Issue Introduction • Virginia JCHC LST Work Group (Mitchell, 2017) – Public comment period through October 12 th • No Action • Introduce legislation to amend § 54.1-2990 – Decision Matrix Meeting November 21 st Decision: No action Joint Commission on Health Care. (2017, November 21). Decision matrix: policy options for 2018 General Assembly session – actions taken. Retrieved from http://jchc.virginia.gov/Decision%20Matrix%202017%20with%20actions%20taken.pdf
Health Policy Issue’s Relevance to Quality & Safety • Population health – Families as a vulnerable population • Experience of care – Communication – Transparency • Cost – Futile care cost estimate The Triple Aim of $4004/day (Huynh et Berwick, Nolan, & Whittington, 2008 al., 2013)
Health Policy Issue’s Relevance to Quality & Safety • Population health, Population Health experience of care, cost plus … Experience • High quality health Cost of Care care includes a focus on clinicians Clinician Health – Meaning in work – Avoiding burnout The Quadruple Aim Bodenheimer & Sinsky, 2014. Sikka, Morath, & Leape 2015.
Implication of Policy Action/Inaction • Current Virginia statistics (Mitchell, 2017) – 56% of health systems surveyed have a written process for managing intractable treatment conflict – 7 of 8 health systems without a written process believe a process is needed • 5 of 7 identified lack of legislative clarity as a barrier
Implication of Policy Action: Amendment Proposed and Passed • Patients – Protections against discrimination (Mitchell, 2017) • Surrogate – Clear process with opportunity for participation (Mitchell, 2017) – Potential relief at removal of decision-making pressures (Fine & Mayo, 2003) • Clinicians – Legislative protections if process followed (Mitchell, 2017) – Impact on moral distress
Implication of Policy Inaction: State Statute Remains Unchanged • Continue current practices – Variability for patients, surrogates, and clinicians based on health system/organization • Lack of clarity about actions to take after 14-day period • Current Virginia statistics (Mitchell, 2017) – 40 cases over 12 months in hospitals with a policy • On average (by health system), 5% cases resulted in withdrawal/withholding over objection – Hospitals without a policy estimate 45-90 cases/yr
Theoretical Frame of Reference • Information indicates the existence Problem Stream of a problem • Available solutions Window of Policy Stream Opportunity • Policy-makers/administration have Political Stream motive and opportunity to act Overview of the Kingdon Model (Kingdon, 1995)
Integrating Policy and Theory: Kingdon and Treatment Conflict in Virginia • Treatment conflict Problem Stream • Common and impactful • Lack of legislative clarity • National guidance documents (Bosslet et Window of Policy Stream al., 2015; Kon et al., 2016) Opportunity • Draft language from JCHC LST Work Group • November Elections Political Stream • House of Delegates, Executive Branch • JCHC recommendation
Stakeholder Analysis • Three primary stakeholder groups – Patients and families – Clinicians – Healthcare organizations • Represented by multiple associations and groups, with some crossover
Government Health Systems & Professional Disability & Aging Religious Agencies & Officials Organizations Organizations Rights Groups Organizations Virginia Dept. of Bon Secours Medical Society of disAbility Law The Family Aging & Rehab. Virginia Virginia Center of Va. Foundation of Services Virginia Virginia Dept. of Carillion Clinic Virginia Assoc. for LeadingAge Virginia Virginia Catholic Health Hospices & Conference Palliative Care Va. Dept. of Health Inova Health Virginia Assoc. of The Arc of Northern Virginia Society for Professions System Health Plans Virginia Human Life Delegate Mary Washington Virginia Healthcare Va. Assoc. of Center Christopher Stolle Healthcare Assoc. – Va. Centers for Independent for Assisted Living Living Riverside Health Virginia Hospital & Va. Caregiver System Healthcare Assoc. Coalition Sentara Healthcare Virginia Nurses Assoc. Univ of Va. Health Virginia Trial System Lawyers Assoc. Va. Commonwealth University LifeNet Health
Stakeholder Differentiation High Influence, Less Interested High Influence, Highly Interested Virginia Department of Aging and Rehabilitative Delegate Stolle Services Bon Secours Health System Virginia Department of Health Carilion Clinic Virginia Department of Health Professions Inova Health System Medical Society of Virginia Sentara Healthcare Virginia Association of Health Plans University of Virginia Health System Virginia Association for Hospices and Palliative Care Virginia Commonwealth University Health System Virginia Nurses Association Virginia Hospital and Healthcare Association Virginia Trial Lawyers Association disAbility Law Center of Virginia LeadingAge Virginia Virginia Association of Centers for Independent The Family Foundation of Virginia Living Virginia Catholic Conference Low Influence, Less Interested Low Influence, Highly Interested LifeNet Health Mary Washington Healthcare Virginia Health Care Association-Virginia Center for Riverside Health System Assisted Living The Arc of Northern Virginia Virginia Caregiver Coalition Virginia Society for Human Life
Stakeholder Mobilization • By December 20, 2017, members of the LST Workgroup will determine whether or not to pursue a legislative outside of the JCHC decision. • By January 15, 2018, additional stakeholders will be identified who represent the interests of surrogate decision-makers and of individuals with disabilities. • By February 1, 2018, stakeholders from the LST Workgroup will identify and contact key members of the General Assembly. • By March 1, 2018, representatives from VHHA member organizations will draft a sample hospital policy that is consistent with the requirements of the proposed amendment.
Environmental Scanning Sociocultural Legal Standards Political • Concern about • Marsala v. • Multi-society • Shift in death panels Yale-New position Virginia House and Haven statement on of Delegates governmental Hospital responding to • Re-election of control of requests for • Kelly v. Delegate healthcare inappropriate Methodist Stolle decisions treatment Hospital • Election of (Bosslet et al., • Media • Threats to Ralph 2015) attention to TADA Northam Charlie Gard case
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