Palliative care and POLST in
the emergency department
Terri Schmidt MD, MS
Professor of Emergency
Attending Inpatient Palliative
Medicine Team
OHSU
February, 2012
Goals of Care
• What were you hoping would happen when
you came to the emergency department
today?
• What has your doctor told you about what
you can expect in the future?
“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.”
ED Palliative Medicine Consults
• In house Monday through Friday 9am to 5 pm
• After 5 pm by phone Monday through Thursday (Goal
24/7)
• Consider admission to OBS with am consult (can put
electronic order request in EPIC)
• Inpatient & Ed consults: Eric Walsh MD, Paul Bascom MD,
Terri Schmidt MD, Mary Denise Smith Advance Practice
Nurse
• Outpatient appointments: Eric Fromme MD, Paul Bascom
MD
Emergency Rule
patient lacks decision capacity
no one legally authorized to act for patient is
available
serious risk of bodily injury or death if a
decision is not made quickly
a reasonable person would consent
Surrogate decision makers
• Standard
– Patient expressed preferences
– Best interest
• Hierarchy
– Legally appointed guardian
– Durable power of attorney for health care
– Spouse or partner of a registered domestic union
– Majority of adult children
– Parent
– Majority of adult siblings
– Other friend or relative
– Attending physician
Determining capacity
Risks and benefits explained to patient
 Patient understand risks and benefits
Make decision based on life values and goals
Consistent over time
ability to communicate a decision
• Reassess for each decision
ED physician & non-beneficial
• No obligation to provide non-beneficial
interventions
• Based on goal of intervention
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
Purpose
To express values and Medical orders which
appoint a surrogate
turn a patient’s values
(future
wishes)
For persons of any age
with advanced illness
into action (applies
today)
Guide actions by Usually not
Emergency
Medical
Personnel
Guide treatment Yes
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
Newest revision June 2011
Voluntary process in Oregon, legislated in
some other states including Washington
• Endorsed programs in 12 states and
developing in over 30
• National POLST Taskforce
“If I am
unconscious at
the last moment
then I don’t want
any machines or
anything.”
Oregon 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 lifesustaining 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.”
– Mandate for signers to enter POLST into Registry unless patient opts
out. Completion of a form is voluntary
Requirements for a Form Valid
• Patient name
• Resuscitation orders
• Health professional 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)
Section A:
Cardiopulmonary Resuscitation (CPR)
5/19/2011
Section B
Medical Interventions
4/9/2015
Section C
ARTIFICIALLY ADMINISTERED NUTRITION
4/9/2015
Section D DOCUMENTATION OF
DISCUSSION
4/9/2015
SIGNATURES
4/9/2015
Legal case
• Can I be liable for not honoring a form?
• California case
• Case filed against an ED physician for not
honoring a POLST order to not intubate
Difficult situations
• Family conflict
• How do you interpret Attempt Resuscitation
and Limited Interventions?
• Trauma
Suicide
• Emergency physicians may be required to
care for patients at the end-of-life who
attempt suicide (without physician
assistance)
• Physicians should counter the medical
effects of suicide attempt unless such
measures would only prolong the dying
process or would be ineffective
The Oregon POLST Registry
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
• Over 80,000 forms currently in Registry
• Entering about 3200 new forms/month
Calls as of January 31, 2012
• 1085 calls
• 335 matches
• 31% match rate
Reasons for Calls
12/3/2009 to 8/31/2010
• 183 EMS the Registry
• 93 calls (51%) were for patients with
trauma, SOB, acute illness but not arrest
• 38 calls (21%) patients in cardiac arrest
• 16 calls (9%) patients with terminal illness
• 3 calls (1%) were patients in respiratory
arrest
Users
• Emergency departments 46%
• EMS
36%
• Acute care
17%
How to access the a POLST in the Registry
• Call the ECC (4-7551 or 4-7333)
• They need enough info to
accurately ID patient (usually can
get it from EPIC
•Name
•Date of Birth
•Gender
•Last 4 SSN
•POLST Registry ID #
•Address
Pain Management
• Trick of the trade
Free IPhone app:
Opioids
Equianalgesic doses
of opioid analgesics
 Morphine (MS) 1 mg IV = 3 mg po
 MS 30 mg po = oxycodone 20-30 mg po
 Hydromorphone 1mg IV = MS 7 mg IV
 MS 5 mg IV = fentanyl 50 mcg
. . . Changing opioids
• Cross-tolerance
– start with 50%–75% of equianalgesic dose
• more if pain not well controlled, less if adverse effects
Breakthrough dosing
• Use immediate-release opioids
– 5%–15% of 24-h dose
• Do NOT use extended-release opioids
• Avoid acetaminophen toxicity
Allergy vs. adverse effect
• Opioid-induced nausea/vomiting,
constipation, drowsiness, confusion are NOT
allergic reactions
• Anaphylaxis, urticaria, pruritus with rash but
RARE
• If true allergic reaction, replace with opioid of
a different class
Urticaria, pruritus (no rash)
• Morphine, hydromorphone, usually not
fentanyl
• Mast cell destabilization followed by
histamine release
• Manage with antihistamines or change to
fentanyl
Trick of the trade…pain crisis
• Morphine 1 mg IV q minute to total 10 mg,
monitoring at bedside for effect,
somnolence, respiratory depression
• Wait 10 minutes
• Repeat until satisfactory pain control
(Alternatives hydromorphone .2 mg or
fentanyl 20 mcg)
Pathophysiology
nausea/vomiting
Antiemetics
• Dopamine antagonists: haloperidol,
prochlorperazine, droperidol, promethazine,
metoclopramide (also prokinetic)
• Antihistamine: diphenhydramine
• Anticholinergic: Scopolamine
• Serotonin antagonists: ondansetron, granisetron
• Other: dexamethasone, THC, lorazepam
Trick of the trade: Haloperidol is a
great antiemetic!
Antacids
• H2 receptor antagonists
– cimetidine
– famotidine
– ranitidine
• Proton pump inhibitors
– omeprazole
– lansoprazole
• Misoprostol
POLST Information
Center for Ethics in Health Care, OHSU
• 503 494-3965
• Fax: 503 494-1260
• Ethics@ohsu.edu
• www.polst.org