Terri Schmidt MD, MSCenter for Ethics in Health Care

Department of Emergency Medicine

Oregon Health & Sciences University

American Medical Responseschmidtt@ohsu.edu

Philosophy of POLSTIndividuals 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

Philosophy of EMSDesigned in the 1960s and 1970sEmergency response to save livesUnderlying assumption that people want

everything doneAssumes primary cardiac arrest (V Fib)

RealityCurrent survival to hospital discharge from

out-of-hospital cardiac arrest is 5% or lessMany cardiac arrests are in patients with

terminal illnessEMS 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

Reality continuedDNR orders are very helpful to EMS when

the person is in cardiac arrestDNR orders are inadequate because they do

provide direction for patients in extremis but not yet in arrest

Idea Spreading Across the CountryOregon- Voluntary in 1991 Utah- DHS Regulation in 2002-3West Virginia- Statute in 2002

West Virginia Health Care Decisions ActWashington-DHS RegulationNew York- Voluntarily by upper NY regions

with numerous existing state regulations and statutes

Developing ProgramsDeveloping Programs*As of October 2007

National POLST Paradigm Initiative Programs

Established ProgramsEstablished Programs

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

Keys to successWork in tandem with EMSHave an EMS championKnow how EMS works in your state and the

regulations that bind them (state mandated out-of-hospital DNR forms)

Work with EMS medical directorsListen to colleagues’ concerns

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)

EMS studySchmidt 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.

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

Findings572/1048 (55%) response rate76% male66% paramedics

Findings continued73% had treated a patient with a POLSTPOLST, 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

Findings continued25% reported some difficulty finding the form87% were filled out appropriately

6% had conflicting orders5% unsigned2% incomplete

Findings continuedIt was not followed in 37 (10%) cases

17 changed by family or other care giver on scene

9 changed by patient8 changed by physician/EMT/hospital

Where EMS should look for POLSTThe front of the chart In a red envelop on the fridge