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The POLST Paradigm: Respecting Patient Preferences. Terri Schmidt MD, MS Center for Ethics in Health Care Department of Emergency Medicine Oregon Health & Sciences University Clackamas County EMS. Purpose of POLST.
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The POLST Paradigm:Respecting Patient Preferences Terri Schmidt MD, MS Center for Ethics in Health Care Department of Emergency Medicine Oregon Health & Sciences University Clackamas County EMS
Purpose of POLST • To provide a mechanism to communicate patient preferences for end-of-life treatment across treatment settings
“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
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
Development of POLST • Consensus development • Began in 1991 • Ongoing revision process • Voluntary process in Oregon, legislated in some other states • Now used in more than 30 states • National POLST Advisory panel
Elements of the POLST Paradigm • Medical order form • Accompanies patient • Bright, unique color (Pink in OR, Green in WA) • Training of professionals • DNAR orders • Limit or provide other interventions • Decisions about transport, ICU, nutrition, antibiotics
“If I am unconscious at the last moment then I don’t want any machines or anything.”
Oregon Regulations that facilitated POLST • Advance Directive Statute (ORS 127.531) • 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 • Directive by OMB that physicians honor it in emergency departments
Requirements to Make the Form Valid • Patient name • Resuscitation orders • Provider signature and date all other information is optional…in Oregon it does not require signature of patient (verbal orders signed by an RN are acceptable)
Validation of POLST • Dunn PM, Schmidt TA et al: A method to communicate patient preferences about medically indicated life sustaining treatment JAGS 1996;44:785 • Tolle SW, Tilden VP, Nelson CA, Dunn PM: A Prospective study of the efficacy of the POLST JAGS 1998;46:1097 • Lee MA, Brummel-Smith K et al: Physician orders for life-sustaining treatment (POLST): Outcomes in a PACE program JAGS 2000; 48:1-6.
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. • Hickman SE, Tolle SW, Brummel-Smith K, Carley MM: Use of POLST (The Physician Orders for Life-Sustaining Treatment Program) in Oregon Nursing Facilities JAGS 2004;52:1424-2 • Hickman SE, Nelson CA, Perrin NA, Moss AH, Hammes BJ, Tolle S: A comparison of methods tp communicate treatment preferences in nursing facilities: Traditional practices versus the physician orders for life-sustaining treatment program JAGS 2010 Jul;58(7):1241-8.
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
Where to keep the POLST • The front of the chart • In a red envelop on the fridge (but people do not like it)
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 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 • Date of Birth • Gender • Last 4 SSN • POLST Registry ID # • Home address/residential care facility address • 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. • THE STAFF ARE NOT MEDICAL PROVIDERS, AND CAN OFFER NO INTERPRETATION OF POLST ORDERS • Hospitals can be faxed the POLST form. • EMS: if you are transporting confirm your destination hospital and a copy can be sent ahead.
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/OregonPOLSTRegistry.htm
POLST Information Center for Ethics in Health Care • 503 494-3965 • Fax: 503 494-1260 • Ethics@ohsu.edu • www.polst.org