The Patient’s got a POLST…now what?

1. Treating the person with a POLST in crisis The Patient’s got a POLST…now what?

2. Purpose of POLST To provide a mechanism to communicate patient preferences for end-of-life treatment across treatment settings

3. POLST Basics • What do you look for first? • Patient name • MD/DO/PA or NP signature • Is there a T/O or V/O (verbal orders) signed by an RN? --these are ok! • Date signed • If the above criteria are not met, the form is not a valid medical order

4. Onto the orders • Section A: Cardiopulmonary Resuscitation • When does section A apply? • ONLY when the patient is NOT breathing AND is pulseless. Section A POLST-isms “Until they die, it doesn’t apply” “Once they’re dead, go ahead”

5. Section B: Medical Interventions • When does section B apply? • When the patient still has a PULSE and/or is still BREATHING Section B POLST-isms “Heart’s got a beat? See Section B for how to treat!” “Is the patient still breathing? Then interventions they’ll be receiving”

6. Section B: Comfort Measures Only • Do: any intervention that will help keep the patient comfortable • Do: Try to resolve care concerns that are manageable by the providers on scene • If the issue becomes larger, consider calling OLMC • Consider transporting only when the patient cannot be kept comfortable at their primary location • Does not mean do not treat!

7. Section B: Limited Additional Interventions • Do simple, minimally invasive interventions • Avoid intubation • Do: Transport if there is a simple medical intervention that can be provided by the ED or hospital

8. Section B: Full Treatment • Treat as per your standard of care for that particular condition!

9. Scenario 1: • EMS arrives at the home of a 78yom c/o SOB, GCS 15. Pt’s son is on scene and presents you with a POLST that is signed by the physician but bears no patient signature. PMH: COPD, HTN • Can you follow the orders? • Form states DNR, Limited Additional Interventions • Which order is most relevant in the patients’ current medical state? • What treatments would you consider?

10. Scenario 2: POLST & the CA pt • Arrive on scene of a 52 year old woman, thin and ill- appearing with metastatic breast cancer. She is c/o new onset nausea and pain in her jaw. • What else do you need to know? • Before seeing a POLST form what treatments are you considering?

11. Scenario 2: 12-lead results Kern, Morton MD “The Different Presentations of Acute STEMI: What Problems Should the Cath Lab Look For?” 12/30/10; www.cathlabdigest.com

12. Now what? • Do you transport? • Would your decision to transport change if you were able to control the patient’s pain on scene? • If you decide to transport where do you transport to? • What info should you relay to the receiving hospital besides that this is a STEMI patient?

13. Quiz time! • Can you follow POLST orders that are from a different state than Oregon? • Yes! (Question… contact OLMC) • Are copies of POLST form ok?? • Yes!

14. Scenario #3 • 72yom, general malaise who stated “I just don’t feel right.” • What is the first thing you need to find out? • The patient is awake and c/o CP & SOB. • Monitor shows V-tach • Treatments? • You decide you’d like to cardiovert • What do you explain to the patient? • Cardiovert asystole • Now what?

15. Quiz time! • When do you consider using CPAP on the patient with a POLST order of CMO? • The patient has to be alert enough to cooperate in order to try CPAP. • Is it helping? • Yes—then this is a comfort measure • No—then take it off, and try something else

16. Scenario 4: I’ve fallen and I can’t get up! • 88 year old woman falls at care facility. GCS13. BP 94/70, P 96; unstable pelvis. • RN on scene hands you POLST form: DNR, CMO • Does the POLST form influence your decision to transport? • Does it change the destination?

17. It’s easy! The Oregon POLST Registry

18. When should I call? • Elderly, frail patients • Terminally ill patients • Chronic, progressive illness patients • If someone states there may be a POLST but cannot provide a copy • If you are not certain the POLST for you have is current

19. What is the Oregon POLST Registry? • Secure electronic database of POLST forms. • Owned by the state of Oregon,operated by the Emergency Communication Center at OHSU and available statewide. • Emergency medical professionals treating a patient can access POLST orders if the original POLST form cannot be immediately located.

20. How do I access the POLST Registry? For emergent needs • Call the POLST Registry EMS Hotline* • State: “This is <your name & title> from<Agency name>, with a POLST form request” • Provide some of the following patient identifiers, as requested by the Registry Hotline staff: • Full name • Date of Birth • Gender • Last 4 SSN • POLST Registry ID # • Home address/residential care facility address • City, County, or zip code *this number is available for EMS, ED and acute care hospital unit use ONLY. It is not for public distribution or dissemination

21. Do I need to have all those identifiers? • NO! • If possible, start with these identifiers • Registry ID • This may be present in a person’s personal effects on a bright pink sticker (example right) • Date of Birth • First and last name • Hotline staff may request additional identifiers to confirm the identity of a patient

22. What information will be provided? • The Registry staff can verbally relay: • Section A and B orders • Date the form was signed • Patient’s POLST Registry ID • THE STAFF ARE NOT MEDICAL PROVIDERS, AND CANNOT INTERPRET POLST ORDERS • If you need guidance, contact On-Line Medical Control

23. Transporting? • Let us know! We will fax a copy of the POLST to your destination hospital

24. What do I document? • Verbal orders relayed • Example: DNR; Limited additional interventions • Date the form was signed • POLST Registry ID You can always call the business office and request a copy of the POLST for your chart. Calls received after hours will be faxed the next business day

25. The Oregon POLST Registry Office • EMS Contact Jenny Cook, Oregon POLST Registry Liaison • Call for any non-urgent questions, or educational information or onsite training requests. • Phone: 503-494-1230 • Toll free: 877-367-7657 • Fax: 503-418-2161 • E-mail: polstreg@ohsu.edu • Website: www.orpolstregistry.org