Article

The Oregon Physician Orders for Life-Sustaining Treatment Registry: A Preliminary Study of Emergency Medical Services Utilization.

Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
Journal of Emergency Medicine (Impact Factor: 1.18). 01/2013; DOI: 10.1016/j.jemermed.2012.07.081
Source: PubMed

ABSTRACT BACKGROUND: The Physician Orders for Life-Sustaining Treatment (POLST) form translates patient treatment preferences into medical orders. The Oregon POLST Registry provides emergency personnel 24-h access to POLST forms. OBJECTIVE: To determine if Emergency Medical Technicians (EMTs) can use the Oregon POLST Registry to honor patient preferences. METHODS: Two telephone surveys were developed: one for the EMT who made a call to the Registry and one for the patient or the surrogate. The EMT survey was designed to determine if the POLST form accessed through the Registry changed the care of the patient. The patient/surrogate survey was designed to determine if the care provided matched the preferences on the POLST. When feasible, the Emergency Medical Services (EMS) record was reviewed to determine whether or not treatment was provided. RESULTS: During the study period there were 34 EMS calls with matches to patients' POLST forms, and 23 interviews were completed with EMS callers, for a response rate of 68%. In seven cases (30%) the patient was in cardiopulmonary arrest; one patient had a respiratory arrest with a pulse. Eight respondents (35%) reported that the patient was conscious and apparently able to make decisions about preferences. For 10 cases (44%) the POLST orders changed treatment, and in six instances (26%) they affected the decision to transport the patient. For the 10/11 patients or surrogates interviewed, the care reportedly matched their wishes. CONCLUSION: This small study suggests that an electronic registry of POLST forms can be used by EMTs to enhance their ability to locate and honor patient preferences regarding life-sustaining treatments.

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    ABSTRACT: Since its original development in Oregon in 1993, Physician Orders for Life-Sustaining Treatment (POLST) is quickly growing in popularity and prevalence as a method of communicating the end-of-life care preferences for the seriously ill and frail nationwide. Early evidence has suggested significant advantages over advance directives and do-not-resuscitate/do-not-intubate documents both in accuracy and penetration within relevant populations. POLST also may contribute to the quality of end-of-life care administered. Although it was designed to be as clear as possible, unexpected challenges in the interpretation and use of POLST in the emergency department do exist. In this article, we will discuss the history, ethical considerations, legal issues, and emerging trends in the use of POLST documents as they apply to emergency medicine.
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    ABSTRACT: We would like to respond to Drs. Mirarchi and Cammar-ata's letter regarding our article, "The Oregon POLST Registry: A preliminary study of EMS utilization" (1). First, we appreciate your interest in patient safety and certainly share it. We would, however, appreciate a clearer definition of the threat to patient safety. We assume it is either not getting care that you did want or getting care that you did not want. We wonder if the risk might not be even higher if there is no Physician's Or-ders for Life-Sustaining Treatment (POLST) form or advance directive. We also share your concern that health care profes-sionals may, at times, misinterpret a do not resuscitate (DNR) order to mean "do not treat" when, as you note, these orders only apply when the patient is in cardiopul-monary arrest. One of the reasons that POLST was designed was to address that issue. The Scope of Treat-ment orders are designed to help direct treatment when the person is not in cardiopulmonary arrest. Therefore, we believe that the POLST orders decrease the likelihood of overly relying on DNR orders. Although our sample size was small, our study showed that emergency medical technicians were able to correctly interpret the orders on the form and that surrogates believed that the patient received the level of treatment that they would have wanted. We also strongly agree that the quality of the docu-ments is a reflection of the quality of the conversation. POLST is not an end in itself but rather the documenta-tion of a process. While the purpose of our study was not to assess the quality of goals of care conversations, we agree on the importance of education for health pro-fessionals about how to have these conversations and the need for health systems to develop education and pro-cedures to help facilitate conversations. POLST orders are not advance directives and no advance directive documents are contained in the Oregon POLST Registry. Although patients may have both an advance directive and POLST for turning their wishes into medical orders, most people who have an advance directive are planning for future health events that may happen years or even decades in the future. POLST is de-signed to apply in the patient's current state of health. Therefore, the references to studies about advance direc-tives do not apply. Although beyond the intent of this study, there is a growing body of evidence showing that the POLST paradigm is effective in conveying patient preferences for, or against, resuscitation. In the first study of portable medical orders (then called a Medical Treatment Cover-sheet), the authors used theoretical scenarios to deter-mine whether or not 19 primary care physicians, 20 emergency physicians, 26 paramedics, and 22 long-term care nurses could correctly interpret the orders. Overall, providers were able to correctly identify treat-ments to provide or withhold (2). A study of 180 nursing home patients at one facility who had a POLST form indicating "do not attempt resuscitation" and "comfort measures only" were prospectively followed for 1 year. During that time, 38 died. The authors found that for these nursing home residents, 100% of the orders regarding cardiopulmonary resuscitation (CPR) were honored (3). The charts of all patients (n = 58) who died in a Program of All-Inclusive Care for the Elderly (PACE) during 1 year were reviewed. All but one had a POLST form. The authors found that the form was generally effective in limiting unwanted interventions. Specifically, the POLST indicated "do not attempt resuscitation" for 50 participants and CPR use was consistent with these instructions for 49 participants (91%) (4). A study of the use of POLST in three states surveyed 71 hospice programs that use POLST and did a chart review in 15 programs. Treatment limitations were respected in 98% of cases and no one received un-wanted CPR (5). Another study by Hickman et al. confirmed a strong association between how a patient's POLST form was marked related to Scope of Treatment orders in section B and the treatments patients received (6). A recent study of concordance of POLST orders with patient or surrogate recall of their preferences did find that 72% of forms were concordant (7). This is higher than the less than one third reported in another recent study, but it still means that there is a group of patients whose preferences may not be correctly conveyed (8).
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