The POLST Paradigm: Your partners in EMS

1. 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@ohsu.edu

2. 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

3. 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)

4. 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

5. 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

6. Case study…Why we need a POLST paradigm

7. 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

8. 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)

9. 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

10. 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)

12. 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 2004;52:1430-34.

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

14. Findings • 572/1048 (55%) response rate • 76% male • 66% paramedics

15. Findings continued • 73% had treated a patient with a POLST • POLST, when present, changed treatment in 45% of patients

16. 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

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

18. 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

19. Case Study: When POLST Works

20. Where EMS should look for POLST • The front of the chart • In a red envelop on the fridge