Establishing patient-centered goals of care and treatment limitations is an important component of care in patients facing advanced illness. At the same time, communication during serious illness can be difficult for patients as well as providers. Research has demonstrated that the ethical ideal for decision making, involving shared decision making between an informed patient and a physician knowledgeable in both the patient's values and achievable treatment outcomes, is far from the norm in clinical practice. Improving communication about goals of care and treatment limitations requires that providers and patients (or their surrogates) develop a shared understanding of desired and achievable outcomes, which can be accomplished by incorporating key principles and a step-wise approach to the goals of care discussion. This approach leads to high levels of patient satisfaction as well as treatment decisions that truly reflect the patient's goals.

SCAN strongly encourages members to prepare advance directives.

We ask our health practitioners and physicians to reinforce the importance of advance directives to our members, and prominently display a copy of the advance directive in the medical record. Please refer to the SCAN Provider Operations Manual for more details.

Below are five kinds of Advance Directives and community resources to help assist you to educate our members on the importance of completing this information.

1. Five Wishes Advanced Directive Form
   Five Wishes lets your family and doctors know:
   
   • Who you want to make health care decisions for you when you can't make them.
   • The kind of medical treatment you want or don't want.
   • How comfortable you want to be.
   • How you want people to treat you.
   http://www.agingwithdignity.org/five-wishes.php
   
   
2. Living Will
   
   
3. POA HealthCare
   
   
4. POA Mental Health Care
   
   
5. DNR
   
   

You can have Advance Directives registered with the Arizona Registry at www.azsos.gov/advdir or call 1-800-458-5842.

Resources and Other Information

The following organizations provide Advance Directive forms and/or information:

Department of Economic Security
Aging and Adult Administration
www.azdes.gov/aaa
(602) 542-4446

Dorothy Garske Center
Your Health Care Choices Program
www.dgcenter.org
(480) 966-2674

Arizona Attorney General’s Office
www.azag.gov
(602) 542-5025

Arizona Center for Disability Law
www.acdl.com
(602) 274-6287

Health Care Decisions
www.hcdecisions.org
(602) 222-2229

Establishing patient-centered goals of care and treatment limitations is an important component of care in patients facing advanced illness. At the same time, communication during serious illness can be difficult for patients as well as providers. Research has demonstrated that the ethical ideal for decision making, involving shared decision making between an informed patient and a physician knowledgeable in both the patient's values and achievable treatment outcomes, is far from the norm in clinical practice. Improving communication about goals of care and treatment limitations requires that providers and patients (or their surrogates) develop a shared understanding of desired and achievable outcomes, which can be accomplished by incorporating key principles and a step-wise approach to the goals of care discussion. This approach leads to high levels of patient satisfaction as well as treatment decisions that truly reflect the patient's goals.

Five Wishes lets your family and doctors know:

• Who you want to make health care decisions for you when you can't make them.
• The kind of medical treatment you want or don't want.
• How comfortable you want to be.
• How you want people to treat you.

POLST (Physician Orders for Life-Sustaining Treatment) is a form that states what kind of medical treatment patients want toward the end of their lives. Printed on bright pink paper, and signed by both a doctor and patient, POLST helps give seriously ill patients more control over their end-of-life care.

New POLST Form Effective April 1, 2011
Proposed changes to the California POLST Form have been approved by the statewide POLST Task Force and the Emergency Medical Services Authority Commission. The new form will go into effect on April 1, 2011. Previous versions of signed POLST forms remain valid. Click here to preview a copy of the revised form. For a summary of the changes to the form, click here.

Thromboembolism is an enormous problem across the spectrum of medicine. In the US and Europe over 600,000 people will suffer a venous thromboembolism, and nearly 20% will die as a result. The incidence of arterial and venous thromboembolism (VTE) is highly age dependent, contributing significant morbidity and mortality to an aging population.

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, occurring in 1–2% of the general population. Its prevalence is estimated to at least double in the next 50 years as the population ages. AF confers a 5-fold risk of stroke, and one in five of all strokes is attributed to this arrhythmia. Ischemic strokes in association with AF are often fatal, and those patients who survive are left more disabled by their stroke and more likely to suffer a recurrence than patients with other causes of stroke. In consequence, the risk of death from AF-related stroke is doubled and the cost of care is increased 1.5-fold. Appropriate management of the AF patient has been shown to reduce the related morbidity and mortality.

Heart failure is increasing in both incidence and prevalence with roughly 5 million people in the United States having this disorder. This is partially a result of decreased mortality from myocardial infarction as a result of improved treatment, as well as improved treatment of the heart failure itself leading to prolonged survival. Heart failure is a major cause of sudden cardiac death with more than half of the deaths due to heart failure are from sudden cardiac death. The second leading cause of death in heart failur patients is due to progressive heart failure. The most important preexisting condition and the best predictor of sudden death is left ventricular dysfunction, the underlying cause of heart failure.Congestive heart failure is one of the top conditions leading to hospitalization among the elderly. It is important that physicians recognize and treat heart failure with knowledge of therapies that minimize mortality and morbidity.

Release Date: January 13, 2011

Use the following clinical tools, approved by SCAN's Pharmacy and Therapeutics Committee, to help address common geriatric medical conditions and better manage your geriatric patients.

CKD is an increasingly prevenlent problem resulting at least partially from the increased prevelance of diabetes. These trends are expected to continue, which makes it especially important that primary care physicians are up to date on recognizing and managing CKD.

Spirometry is the most commonly performed pulmonary function test (PFT). It is a relatively simple test that can be performed at the bedside, in a physician's office, or in a pulmonary laboratory. It is usually the first test performed to evaluate a potential problem with the lungs function as it helps to narrow the differential diagnosis of dyspnea. Indications for spirometry include an abnormal chest radiograph, arterial blood gas analysis, symptomatic patients with a history of smoking, family history of lung disease, or other abnormal diagnostic pulmonary test result. Regular spirometry tests be performed over time on patients with chronic respiratory ailments including COPD to evaluate rates of decline in lung function. It is also used to evaluate the efficacy of bronchodilator inhalers and help to guide therapy.
Release Date: November 1, 2010

Chronic Obstructive Pulmonary Disease (COPD) is a frequently encountered problem among primary care physicians managing older adults and geriatric patients. The prevalence of COPD has been increasing and although it can be treated, it cannot be cured, which results in it having a significant impact on healthcare.

Use the following clinical tools, approved by SCAN's Pharmacy and Therapeutics Committee, to help address common geriatric medical conditions and better manage your geriatric patients.

The ACP COPD Portal is updated weekly and includes searchable content from MKSAP, Annals of Internal Medicine, ACP Internist, ACP Journal Club, and ACP’s Physicians’ Information and Education Resource (PIER). The Clinician Resources area of the Portal is organized into three categories: quality, practice issues, and clinical topics.

Dementia and associated disorders have increased prevalence with age. Dementia is often associated with other treatable disorders such as depression and delirium. Both are often misdiagnosed and inappropriately managed, thus contributing to the complexity of care, unnecessary service utilization and poor quality of life.

This Six-Item Screener is a quick screening test for cognition that can be used in person or over the telephone.

Use the following clinical tools, approved by SCAN's Pharmacy and Therapeutics Committee, to help address common geriatric medical conditions and better manage your geriatric patients.

The PHQ-2 inquires about the frequency of depressed mood and anhedonia over the past two weeks. The PHQ-2 includes the first two items of the PHQ-9.

The Patient Health Questionnaire (PHQ) can be administered by the patient or health care provider.

Use the following clinical tools, approved by SCAN's Pharmacy and Therapeutics Committee, to help address common geriatric medical conditions and better manage your geriatric patients.

As one ages the possibility of injuring oneself due to falling become an increasing concern to both patients and family members. Health care providers also need to be aware of this not uncommon occurrence since the overall population is aging and will result in an increased incidence of falling.
Release Date: January 6, 2011

The Home Safety Checklist is designed to help you inspect your home and identify potential hazards or problems.

Management of pain is often challenging in the nursing home, particularly because many residents have some type of cognitive impairment that keeps them from readily self-reporting pain. In addition, myths such as the belief that pain should be expected in older adults and fears about potential addiction prevents many older adults and their family members from asking for pain medication. Similar concerns and beliefs by nurses and physicians may also contribute to poor pain management and resident suffering. Nursing homes need to establish a comprehensive program that creates a systematic approach to pain management. A good pain management program needs to be resident focused and include pain assessment, interventions/treatments, monitoring, quality improvement and education for patients, families and staff. By establishing a systematic and comprehensive program, nursing homes can ensure that residents have their pain goals met and do not suffer needlessly.

Thermometer Pain Scale with faces of pain and descriptions.

POLST (Physician Orders for Life-Sustaining Treatment) is a form that states what kind of medical treatment patients want toward the end of their lives. Printed on bright pink paper, and signed by both a doctor and patient, POLST helps give seriously ill patients more control over their end-of-life care.

Proposed changes to the California POLST Form have been approved by the statewide POLST Task Force and the Emergency Medical Services Authority Commission. The new form will go into effect on April 1, 2011. Previous versions of signed POLST forms remain valid. Click here to preview a copy of the revised form. For a summary of the changes to the form, click here.

Osteoporosis is a disease in which bones become fragile and more likely to break. If not prevented or if left untreated, osteoporosis can progress painlessly until a bone breaks. These broken bones, also known as fractures, occur typically in the hip, spine, and wrist.

Use the following clinical tools, approved by SCAN's Pharmacy and Therapeutics Committee, to help address common geriatric medical conditions and better manage your geriatric patients.

Atrial Fibrillation - Incidence of intracranial hemorrhage in patients with atrial fibrillation who are prone to fall

A gap exists between the increased prevalence of stroke in the elderly and appropriate prevention and treatment measures practiced in the community.

Urinary incontinence (UI) is a common and treatable problem, especially in women and the elderly. The prevalence of UI increases with age, but it is not a part of normal aging. In women over age 60 years the prevalence of UI ranges from 15% to 43%. In contrast, the prevalence of UI in men at all ages, ranges from 1.6% to 24%. Despite this, UI remains under diagnosed and underreported with only 32% of primary care physicians routinely asking all of their patients about UI, and 50%-75% of incontinent community-dwelling patients never describing their symptoms to physicians.