"EXCEL" Meeting Minutes
October 23, 2001

Present:
Tim Thompson, Marie Kirn, Denise Niemira, Ginny Fry, Maureen Fraser, John Campbell, Suzanne Parker, Madeleine Mongan, Tasseli McKay

Guest Speaker
Jan Carney (via phone), Dan Mance, Bill Clark, Joe Jacobs, Sue Draper

DNR Orders
Dan Mance gave a brief history of the issue, explaining that existing advanced directives haven’t worked to guide pre-hospital emergency personnel on limiting resuscitation efforts. Currently, resuscitation is performed by default. The Department of Health believes this problem can be addressed without legislative action, since EMS providers are guided in other matters by statewide care protocols rather than statute.

Dr. Wayne Misselbach, state EMS medical advisor, recommended creating a DNR standing order for EMS technicians. Emergency room physicians are reluctant to give the order to withhold resuscitation “in the field” without seeing a copy of the DNR order. This would be addressed if the physician gave a standing order to honor a DNR order present in the patient’s residence.

The Brattleboro DNR pilot project was well received by EMS, nursing home and hospital staff. The process of making DNR orders an option encouraged exchange between physicians and patients about their preferences around resuscitation. EMS providers were told that routine (non-resuscitative) emergency care was to be provided, so the order did not affect other forms of medical intervention. One of the indirect consequences of the project was increased awareness of the choice not to call an ambulance or transfer a nursing home resident to the emergency room.

The Health Department is ready to pursue broader implementation of this project, community by community. They are preparing a team to present the concept to hospice, hospital, nursing home and community groups in each county. They will then work with individuals in each community to tailor and implement the DNR order. The Department intends to visit one county each month with the presentation, beginning with Springfield and finishing by the end of next year. Jeff Bell will attend a medical staff meeting at every Vermont hospital.

Denise Niemira explained that at North Country Hospital, the ER physician signs a DNR order upon releasing a patient from the hospital, or responds to the call from EMS technicians when there isn’t a clear DNR order. Dan Mance pointed out that this system relies on ER physicians’ willingness to verify the order. Tim Thompson said that this informal system might not work at a larger hospital.

John Campbell emphasized the importance of the Health Department in facilitating this process, and agreed that initiative within each local community would be critical. Tim Thompson suggested that the ExCEL committee could help to distribute this information via the website and its hospice and palliative care community contacts. John Campbell said that this would be a natural extension of the Vermont Ethics Network’s advanced directive work.

OxyContin Prior Authorization
Joe Jacobs reported that there has been a sharp drop in requests for OxyContin prior authorization. The delays experienced immediately following PA implementation were due to the initial requests on behalf of existing OxyContin patients and will not be repeated. Joe Jacobs has not gotten a negative reaction from any individual physician he has spoken to during the authorization process.

Tim Thompson noted that the negative publicity around the potential for OxyContin addiction and diversion has created a need for re-education of physicians regarding quality pharmacological pain management. Suzanne Parker agreed that there is a problem with the perception of the drug; some physicians are unwilling to prescribe it because of anxiety about state surveillance of their prescribing practices. The state is creating the inaccurate impression that large numbers of OxyContin prescriptions indicate poor clinical practice, rather than careful attention to pain management.

Suzanne Parker commented that in evaluating a prior authorization request, it’s appropriate to check the condition being treated, but inappropriate to probe further than that. Joe Jacobs argued that such a question wouldn’t get at the addiction issues, ie, is the person seeing multiple physicians, etc. Drs. Parker, Rathmell and Jacobs will work together to further revise the PA form.

Denise Niemira observed that OVHA’s quarterly reports to physicians on their patients’ narcotics prescriptions are very helpful. Physicians are receiving these reports only erratically. Joe Jacobs agreed that EDS should be producing the reports quarterly, and said he would ensure they do in the future.

Tim Thompson asked whether OVHA would be interested in helping to assemble and distribute protocols for pharmacological pain management, including the use of opiates. Joe Jacobs suggested that this activity could be rolled into the First Health physician education contract.

Joe Jacobs told the group that the Board of Pharmacy met with Paul Wallace-Brodeur to discuss pharmacists’ concerns over burglary. A person was arrested recently for attempting to steal OxyContin from a Vermont pharmacy. Sue Draper said that Knight’s Pharmacy won’t be carrying it anymore, and several other pharmacies have already stopped stocking it.

Methadone Prior Authorization
Tim Thompson observed that, although the methadone prior authorization requirement was established to prevent its use in maintenance, the current prior authorization process restricts its use in pain management. He asked that, since methadone is among the best pain medications available (due to its low cost and long half life), its use in pain management not be encumbered or restricted by a prior authorization requirement. Joe Jacobs responded that many people have both pain and addiction issues, which are brought out during the PA process.

Suzanne Parker emphasized the importance of educating physicians and the public about the difference between addiction and physical dependence. She distributed a journal article detailing that difference.

Madeleine Mongan brought up the confidentiality issues involved when an exchange of information to secure prior authorization reveals that a felony has been committed. She asked whether OVHA employees and contractors had an obligation to report this information to the state police. Joe Jacobs will investigate this question.