The POLST Registry & Ethical Treatment in EMS Care

2. The POLST Registry & Ethical Treatment in EMS Care Terri Schmidt MD, MS

3. “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.”

4. Definitions • Advance directives • Directive to physicians/living will • Power of attorney for health care • Do not attempt resuscitation-DNAR • POLST and POLST paradigm (In some states called

6. 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

7. National POLST Development

9. “If I am unconscious at the last moment then I don’t want any machines or anything.”

10. Oregon Administrative Rules • 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 • Oregon Medical Board [OAR 847-010-0110] • 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.”

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

13. Section B Medical Interventions 6/10/2014

14. Section C Artificially Administered Nutrition 6/10/2014

15. Section D DOCUMENTATION OF DISCUSSION 6/10/2014

16. Section E: Signature of Physician / NP/ PA 6/10/2014

17. 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

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

19. Findings • 572/1048 (55%) response rate • 76% male • 66% paramedics

20. 73% had treated a patient with a POLST • POLST, when present, changed treatment in 45% of patients

21. 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

22. 25% reported some difficulty finding the form • 87% were filled out appropriately • 6% had conflicting orders • 5% unsigned • 2% incomplete

23. 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

24. Case Study: When POLST Works

25. The Oregon POLST Registry For Emergency Medical Services, emergency departments and hospital acute care units

26. 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.

27. 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

31. Current calls as of November 30, 2011 920 calls 270 matches 30.1% match rate

34. 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: • Full name • Date of Birth • Gender • Last 4 SSN • POLST Registry ID # • Home address/residential care facility address • City, County, or zip code

35. 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

36. Some examples • Case I – EMS Case • Case 2 – ED Case

37. 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

38. POLST Information Center for Ethics in Health Care • 503 494-3965 • Fax: 503 494-1260 • Ethics@ohsu.edu • www.polst.org

39. Thank you!