POLST: Respecting Patient Wishes Near the End of Life

Terri Schmidt MD, MS
Center for Ethics in Health Care
Department of Emergency Medicine
Oregon Health & Sciences University
American Medical Response
Philosophy of POLST
 Individuals 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 EMS
 Designed in the 1960s and 1970s
 Emergency response to save lives
 Underlying assumption that people want everything
 Assumes primary cardiac arrest (V Fib)
 Current survival to hospital discharge from out-of-
hospital cardiac arrest is 5% or less
 Many cardiac arrests are in patients with terminal
 EMS 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 continued
 DNR orders are very helpful to EMS when the person
is in cardiac arrest
 DNR orders are inadequate because they do provide
direction for patients in extremis but not yet in arrest
Case study…Why we need a POLST paradigm
Idea Spreading Across the Country
 Oregon- Voluntary in 1991
 Utah- DHS Regulation in 2002-3
 West Virginia- Statute in 2002
 West Virginia Health Care Decisions Act
 Washington-DHS Regulation
 New York- Voluntarily by upper NY regions with
numerous existing state regulations and statutes
National POLST Paradigm Initiative
Established Programs
Developing Programs
No Program (Contacts)
*As of October 2007
Designation of POLST Paradigm Program status based on
information available by the program to the Task Force.
Keys to success
 Work in tandem with EMS
 Have an EMS champion
 Know how EMS works in your state and the
regulations that bind them (state mandated out-ofhospital DNR forms)
 Work with EMS medical directors
 Listen 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 study
 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.
Anonymous survey mailed in 2002 to a
stratified random sample of Oregon
paramedics and EMT-Intermediates
 572/1048 (55%) response rate
 76% male
 66% paramedics
Findings continued
 73% had treated a patient with a POLST
 POLST, when present, changed treatment in 45% of
 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 continued
 25% reported some difficulty finding the form
 87% were filled out appropriately
 6% had conflicting orders
 5% unsigned
 2% incomplete
Findings continued
 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
Where EMS should look for POLST
 The front of the chart
 In a red envelop on the fridge