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 (Insome states called

ADVANCE DIRECTIVEPOLST For whomFor all adults For persons of any age with advanced illness Purpose To express values and appoint a surrogate ( future wishes ) Medical orders which turn a patient’s values into action ( applies today ) Guide actions by Emergency Medical Personnel Usually notYes Guide treatment 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

Development of POLST Consensus development Began in 1991 Newest revision June 2011 Voluntary process in Oregon, legislated in some other states including Washington Now used or developing 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, artificial nutrition

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 (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 ] – 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.”

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: 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: 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):

Section A: Cardiopulmonary Resuscitation (CPR) 5/19/2011

Section B Medical Interventions 4/4/2015

Section C A RTIFICIALLY A DMINISTERED N UTRITION 4/4/2015

Section D DOCUMENTATION OF DISCUSSION 4/4/2015

Section E: S IGNATURE OF P HYSICIAN / NP/ PA 4/4/2015

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:

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

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 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, 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” Full name Date of Birth Gender Last 4 SSN POLST Registry ID # Home address/residential care facility address City, County, or zip code Provide as much as possible of the following patient information, to the Registry staff:

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

“My mother was choking. Called because her lips were blue…put her on the floor and did CPR. The medics came and took over. I told them she had a POLST but I couldn’t find it…the form used to be on the fridge but we got a new one and hadn’t moved it there yet. I …[that day] her wishes were honored.” –Daughter of pt “The daughter was the one who informed first responders that the patient had a POLST form which prompted us to call the Registry…All life- saving measures were terminated as soon as orders were announced to honor end of life wishes…The Registry is a good thing. It is a stressful time for family and the ability to call and get the wishes is really helpful–Medic on the scene

“The pt was very old and in cardiac arrest. There was a language barrier at the scene and we were trying to ask the daughter if he had a POLST. Daughter came back with magnet. Without them [the family] the POLST would have never been known to exist…overall, it [call to the Registry] was successful.” -Medic on the scene

“The pt was very old and in cardiac arrest. There was a language barrier at the scene and we were trying to ask the daughter if he had a POLST. Daughter came back with magnet. Without them [the family] the POLST would have never been known to exist…overall, it [call to the Registry] was successful.” -Medic on the scene

“We had dinner, [he] was holding the placemats, and he just went down and collapsed. There was no eye contact, no voice contact. I called and my son and daughter-in-law came over…asked if they wanted to override the POLST and we decided no. This is what he wanted. [His wishes were] definitely honored. [EMS was] professional, quick, and efficient... [The Registry] is a wonderful idea. Should be more publicized so people know where to put it [POLST form]” -Wife of pt

The Oregon POLST Registry Emergency Communication Center at OHSU (MRH) ( POLSTS ) Website:

POLST Information Center for Ethics in Health Care Fax:

Thank you!