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

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) These are the Oregon statures. Oregon�s EMT scope of practice includes language that requires EMTs to honor POLST and to look for it States will vary POLST is a voluntary program in Oregon. In other states, such as West Virginia, it was implemented through the legislative process These are the Oregon statures. Oregon�s EMT scope of practice includes language that requires EMTs to honor POLST and to look for it States will vary POLST is a voluntary program in Oregon. In other states, such as West Virginia, it was implemented through the legislative process

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 A 26 year old man with cystic fibrosis and severe lung involvement arrived by ambulance in the emergency department at 3am in severe respiratory distress, sitting upright, unable to speak and markedly hypoxic. He had a POLST saying comfort measures only, terminal CP. He was in the ED for about 2 hours receiving small doses of medication for comfort, the nurses sat with him throughout that time and he peacefully died in the emergency department.A 26 year old man with cystic fibrosis and severe lung involvement arrived by ambulance in the emergency department at 3am in severe respiratory distress, sitting upright, unable to speak and markedly hypoxic. He had a POLST saying comfort measures only, terminal CP. He was in the ED for about 2 hours receiving small doses of medication for comfort, the nurses sat with him throughout that time and he peacefully died in the emergency department.

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