The POLST Paradigm:Respecting Patient Preferences

Terri Schmidt MD, MSCenter for Ethics in Health Care

Department of Emergency MedicineOregon 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

ADVANCE DIRECTIVE POLST

For whom For 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 not Yes

Guide treatment decisions in the hospital

Yes 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• 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

National POLST Development

Developing Programs*As of April 2010

National POLST Paradigm Programs

Endorsed Programs

No Program (Contacts)Designation of POLST Paradigm Program status based on information available by the program to the Task Force.

“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

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 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:

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.

This is what the fax will look like

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