Transcript POLST: Respecting Patient Wishes Near the End of Life

The POLST Registry &
Ethical Treatment in EMS
Care
Terri Schmidt MD, MS
“If I have cancer or
something, [resuscitation] is
a waste of time, because
you know you’re going to
die. I would like to be in a
hospice situation where
there is someone to hold
your hand or make sure you
are comfortable.”
Definitions
• Advance directives
– Directive to physicians/living will
– Power of attorney for health care
• Do not attempt resuscitation-DNAR
• POLST and POLST paradigm (In some states
called
ADVANCE DIRECTIVE
POLST
For whom
For all adults
Purpose
To express values and Medical orders which
appoint a surrogate
turn a patient’s values
(future
wishes)
For persons of any age
with advanced illness
into action (applies
today)
Guide actions by Usually not
Emergency
Medical
Personnel
Guide treatment Yes
decisions in the
hospital
Yes
Yes
What Is POLST
• A health care
provider’s order
• Can be completed by
others (SW, RN) but
must be signed by MD,
DO, NP or PA
– May be a verbal order
from one of the above,
signed by an RN
• Consistent recognized
document
National POLST Development
National POLST Paradigm Programs
Endorsed Programs
Developing Programs
No Program (Contacts)
*As of April 2010
Designation of POLST Paradigm Program status based on
information available by the program to the Task Force.
“If I am unconscious at
the last moment then I
don’t want any
machines or anything.”
Oregon Administrative Rules
•EMT Scope of Practice [OAR 847-35-0030(6)].
– The Oregon Medical Board has defined the Scope of
Practice so that an Oregon-certified First Responder or
EMT shall comply with life-sustaining treatment orders
executed by a physician, physician assistant or nurse
practitioner
•Oregon Medical Board [OAR 847-010-0110]
– The fact that a physician, physician assistant or nurse
practitioner who executed a life-sustaining treatment
order does not have admitting privileges at a hospital or
health care facility where the patient is being treated does
not remove the obligation under this section to honor the
order.”
Section A:
Cardiopulmonary Resuscitation (CPR)
5/19/2011
Section B
Medical Interventions
4/8/2015
Section C
ARTIFICIALLY ADMINISTERED NUTRITION
4/8/2015
Section D DOCUMENTATION OF
DISCUSSION
4/8/2015
Section E: SIGNATURE OF PHYSICIAN / NP/ PA
4/8/2015
• Schmidt TA, Hickman SE, Tolle SW, Brooks HS:
The Physician Orders for Life-Sustaining
Treatment Program: Oregon Emergency
Medical Technicians’ Practical Experience and
Attitudes JAGS 2004;52:1430-34
Methods
• Anonymous survey mailed in 2002 to a
stratified random sample of Oregon
paramedics and EMT-Intermediates
Findings
• 572/1048 (55%) response rate
• 76% male
• 66% paramedics
• 73% had treated a patient with a POLST
• POLST, when present, changed treatment in
45% of patients
• 75% thought POLST provided clear
instructions about patient preferences
• 93% thought POLST useful in determining
treatment when patient in cardiopulmonary
arrest
• 63% thought it useful in other circumstances
• 25% reported some difficulty finding the form
• 87% were filled out appropriately
– 6% had conflicting orders
– 5% unsigned
– 2% incomplete
• It was not followed in 37 (10%) cases
– 17 changed by family or other care giver on scene
– 9 changed by patient
– 8 changed by physician/EMT/hospital
Case Study: When POLST Works
The Oregon POLST Registry
For Emergency Medical Services, emergency
departments and hospital acute care units
What is it?
• Secure electronic registry of POLST
orders.
• Located at the Emergency
Communication Center at OHSU
and protected by the OHSU firewall
• Allows health care professionals
access to POLST orders if the
original POLST form cannot be
immediately located.
How did it happen?
• Piloted the concept at the county level
• HIPAA concerns made registry difficult
• State law created requiring reporting of POLST
forms made creation possible
– Mandate supported by stakeholders
• Division of duties
– State- funds the registry
– Center for Ethics – responsible for education and
forms
Current calls as of November 30,
2011
• 920 calls
• 270 matches
• 30.1% match rate
How do I access the POLST Registry?
• Call the 24 hour POLST Registry
EMS line
– Say, “This is ______________
agency/emergency department,
with an immediate POLST form
request”
Provide as much as possible of the following patient
information, to the Registry staff:
•Full name
•POLST Registry ID #
•Date of Birth
•Home address/residential
•Gender
care facility address
•Last 4 SSN
•City, County, or zip code
What information will be provided?
• Section A and B orders, the date the form
was signed, and the POLST Registry ID
number.
• Hospitals can be faxed the POLST form.
• EMS: Confirm your destination hospital and a
copy can be sent ahead
• THE STAFF ARE NOT MEDICAL
PROVIDERS AND CANNOT
INTERPRETPOLST ORDERS
Some examples
• Case I – EMS Case
• Case 2 – ED Case
The Oregon POLST Registry
Emergency Communication Center at OHSU
503 494-7333 (MRH)
888 476 5787 (1-888
4-POLSTS)
E-mail: [email protected]
Website:
http://www.ohsu.edu/polst/programs/OregonPOLSTRegistry.htm
POLST Information
Center for Ethics in Health Care
• 503 494-3965
• Fax: 503 494-1260
• [email protected]
• www.polst.org
Thank you!