The POLST Paradigm:
Respecting Patient Preferences
Terri Schmidt MD, MS
Center for Ethics in Health Care
Department of Emergency Medicine
Oregon 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
Medical orders which turn
a patient’s values into
(future wishes)
Usually not
action (applies
Yes
Yes
Yes
Guide actions by
Emergency Medical
Personnel
Guide treatment
decisions in the
hospital
today)
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
National POLST Paradigm Programs
Endorsed Programs
Developing Programs
No Program (Contacts)
*As of April 2010
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 LifeSustaining 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:
•Full name
•POLST Registry ID #
•Date of Birth
•Home address/residential
•Gender
care facility address
•Last 4 SSN
•City, County, or zip code
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