The POLST Paradigm: Your partners in EMS

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The POLST Paradigm Your partners in EMS

• Terri Schmidt MD, MS
• Center for Ethics in Health Care
• Department of Emergency Medicine
• Oregon Health Sciences University
• American Medical Response
• schmidtt_at_ohsu.edu

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Philosophy of POLST

• Individuals have the right to make their own
  health care decisions
• These rights include
• Making decisions about life-sustaining treatment
• Describing desires for life-sustaining treatment
  to health care providers
• Receiving comfort care while having wishes
  honored

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Philosophy of EMS

• Designed in the 1960s and 1970s
• Emergency response to save lives
• Underlying assumption that people want everything
  done
• Assumes primary cardiac arrest (V Fib)

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Reality

• Current survival to hospital discharge from
  out-of-hospital cardiac arrest is 5 or less
• Many cardiac arrests are in patients with
  terminal illness
• EMS does not want to attempt resuscitation when
  it is not wanted but they need documentation
• EMS is often faced with decisions about how to
  proceed for patients with serious illness who are
  not in cardiac arrest

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Reality continued

• DNR orders are very helpful to EMS when the
  person is in cardiac arrest
• DNR orders are inadequate because they do provide
  direction for patients in extremis but not yet in
  arrest

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Case studyWhy we need a POLST paradigm
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Idea Spreading Across the Country

• Oregon- Voluntary in 1991
• Utah- DHS Regulation in 2002-3
• West Virginia- Statute in 2002
• West Virginia Health Care Decisions Act
• Washington-DHS Regulation
• New York- Voluntarily by upper NY regions with
  numerous existing state regulations and statutes

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National POLST Paradigm Initiative Programs
Established Programs
As of October 2007
Developing Programs
Designation of POLST Paradigm Program status
based on information available by the program to
the Task Force.
No Program (Contacts)
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Keys to success

• Work in tandem with EMS
• Have an EMS champion
• Know how EMS works in your state and the
  regulations that bind them (state mandated
  out-of-hospital DNR forms)
• Work with EMS medical directors
• Listen to colleagues concerns

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Oregon regulations that facilitated POLST with
EMS

• EMT Scope of Practice OAR 847-35-0030(6).
• The Oregon Board of Medical Examiners 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, PA or NP
• Current modification also requires EMTs to look
  for one
• (know your own state laws)

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EMS study

• 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
  2004521430-34.

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Methods

• Anonymous survey mailed in 2002 to a stratified
  random sample of Oregon paramedics and
  EMT-Intermediates

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Findings

• 572/1048 (55) response rate
• 76 male
• 66 paramedics

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Findings continued

• 73 had treated a patient with a POLST
• POLST, when present, changed treatment in 45 of
  patients

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• 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

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Findings continued

• 25 reported some difficulty finding the form
• 87 were filled out appropriately
• 6 had conflicting orders
• 5 unsigned
• 2 incomplete

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Findings continued

• 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

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Case Study When POLST Works
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Where EMS should look for POLST

• The front of the chart
• In a red envelop on the fridge

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