The POLST Paradigm: Your partners in EMS
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Transcript of The POLST Paradigm: Your partners in EMS
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Terri Schmidt MD, MSCenter for Ethics in Health Care
Department of Emergency Medicine
Oregon Health & Sciences University
American Medical [email protected]
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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
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Philosophy of EMSDesigned in the 1960s and 1970sEmergency response to save livesUnderlying assumption that people want
everything doneAssumes primary cardiac arrest (V Fib)
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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
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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
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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
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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.
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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
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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)
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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.
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Anonymous survey mailed in 2002 to a stratified random sample of Oregon paramedics and EMT-Intermediates
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Findings572/1048 (55%) response rate76% male66% paramedics
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Findings continued73% had treated a patient with a POLSTPOLST, when present, changed treatment in
45% of patients
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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
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Findings continued25% reported some difficulty finding the form87% were filled out appropriately
6% had conflicting orders5% unsigned2% incomplete
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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
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Where EMS should look for POLSTThe front of the chart In a red envelop on the fridge
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