Policy Issue Identification: 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 current Virginia law pertaining to resolution of life-sustaining treatment conflicts. • Analyze the impact of policy action or inaction from the perspective of the patient, surrogate, and clinician. • Apply Kingdon’s model to policy actions related to life-sustaining treatment conflicts in Virginia.
Health Policy Issue Introduction • Clinician-surrogate conflict over life-sustaining treatment • 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)
Health Policy Issue Introduction • Overview of end-of-life care in the ICU – 65% of deaths preceded by decision to withhold or withdraw LST (Lobo et al., 2017) – 33-38% of patients receive non-beneficial treatments (Cardona-Morrell et al., 2016) • Disagreement about prognosis/treatment common (Pope & Kemmerling, 2016) – Common cause of moral distress (Whitehead, Herbertson, Hamric, Epstein, & Fisher, 2015; Hamric & Epstein, 2017)
Health Policy Issue Introduction • Multi-society position statement: responding to requests for inappropriate or potentially inappropriate treatment (Bosslet et al., 2015) – Seven-step process to resolve conflicts • SCCM policy statement: defining futile or potentially inappropriate treatments (Kon et al., 2016) – No reasonable expectation of improvement that would allow patient to survive outside of the acute care setting, or perceive the benefits of treatment • “Clinicians should recognize the limits of prognostication…”
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 • Studied by Virginia Joint Commission on Health Care in 2016 and 2017: Life-Sustaining Treatment Work Group (Mitchell, 2017) – Survey of health systems in Virginia – Policy options: • No action • Introduce legislation to amend § 54.1-2990 (drafted language) – Public comment period through October 12 th
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’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 Window of Policy Stream • Bosslet et al., 2015. Opportunity • Kon et al., 2016. • November Elections Political Stream • House of Delegates • Executive Branch
Learning Objectives • Understand current Virginia law pertaining to resolution of life-sustaining treatment conflicts. • Analyze the impact of policy action or inaction from the perspective of the patient, surrogate, and clinician. • Apply Kingdon’s model to policy actions related to life-sustaining treatment conflicts in Virginia.
References • Berwick, D. M., Nolan, T. W., & Whittington, J. (2008). The triple aim: Care, health, and cost. Health Affairs (Project Hope), 27 (3), 759-769. doi:10.1377/hlthaff.27.3.759 • Bodenheimer, T., & Sinsky, C. (2014). From triple to quadruple aim: Care of the patient requires care of the provider. Annals of Family Medicine, 12 (6), 573-576. doi:10.1370/afm.1713 • Bosslet, G. T., Pope, T. M., Rubenfeld, G. D., Lo, B., Truog, R. D., Rushton, C. H., . . . Society of Critical Care. (2015). An official ATS/AACN/ACCP/ESICM/SCCM policy statement: Responding to requests for potentially inappropriate treatments in intensive care units. American Journal of Respiratory and Critical Care Medicine, 191 (11), 1318-1330. doi:10.1164/rccm.201505- 0924ST • Cardona-Morrell, M., Kim, J., Turner, R. M., Anstey, M., Mitchell, I. A., & Hillman, K. (2016). Non-beneficial treatments in hospital at the end of life: A systematic review on extent of the problem. International Journal for Quality in Health Care : Journal of the International Society for Quality in Health Care, 28 (4), 456-469. doi:10.1093/intqhc/mzw060 • Fine, R. L., & Mayo, T. W. (2003). Resolution of futility by due process: Early experience with the Texas advance directives act. Annals of Internal Medicine, 138 (9), 743-746. doi:200305060-00011
References • Hamric, A. B., & Epstein, E. G. (2017). A health system-wide moral distress consultation service: Development and evaluation. HEC Forum : An Interdisciplinary Journal on Hospitals' Ethical and Legal Issues, doi:10.1007/s10730-016-9315-y • Huynh, T. N., Kleerup, E. C., Wiley, J. F., Savitsky, T. D., Guse, D., Garber, B. J., & Wenger, N. S. (2013). The frequency and cost of treatment perceived to be futile in critical care. JAMA Internal Medicine, 173 (20), 1887-1894. doi:10.1001/jamainternmed.2013.10261 • Kingdon, J. W. (1995). The policy window, and joining the streams. In Agendas, alternatives, and public policies (2nd Ed., pp. 165-195). New York: Longman. • Kon, A. A., Shepard, E. K., Sederstrom, N. O., Swoboda, S. M., Marshall, M. F., Birriel, B., & Rincon, F. (2016). Defining futile and potentially inappropriate interventions: A policy statement from the society of critical care medicine ethics committee. Critical Care Medicine, 44 (9), 1769-1774. doi:10.1097/CCM.0000000000001965 • Lobo, S. M., De Simoni, F. H. B., Jakob, S. M., Estella, A., Vadi, S., Bluethgen, A., . . . ICON investigators. (2017). Decision-making on withholding or withdrawing life support in the ICU: A worldwide perspective. Chest, 152 (2), 321-329. doi:S0012-3692(17)30820-6
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