The POLST Registry Ethical Treatment in EMS Care

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

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

“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 10/27/2021

Section C Artificially Administered Nutrition 10/27/2021

Section D DOCUMENTATION OF DISCUSSION 10/27/202 1

Section E: Signature of Physician / NP/ PA 10/27/2021

• 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: polstreg@ohsu. edu Website: http: //www. ohsu. edu/polst/programs/Oregon. POLSTRegistry. htm

POLST Information Center for Ethics in Health Care • 503 494 -3965 • Fax: 503 494 -1260 • Ethics@ohsu. edu • www. polst. org

Thank you!