POLST: Respecting Patient Wishes Near the End of Life

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Palliative care and POLST in the emergency
department

• Terri Schmidt MD, MS
• Professor of Emergency
• Attending Inpatient Palliative Medicine Team
• OHSU
• February, 2012

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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?

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If I have cancer or something, resuscitation
is a waste of time, because you know youre 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.
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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

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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

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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

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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

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ED physician non-beneficial

• No obligation to provide non-beneficial
  interventions
• Based on goal of intervention

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Definitions

• Advance directives
• Directive to physicians/living will
• Power of attorney for health care
• Do not attempt resuscitation-DNAR
• POLST and POLST paradigm

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ADVANCE DIRECTIVE POLST
For whom For all adults  For persons of any age with advanced illness
Purpose To express values and appoint a surrogate (future wishes) Medical orders which turn a patients values into action (applies today)
Guide actions by Emergency Medical Personnel Usually not Yes
Guide treatment decisions in the hospital Yes Yes
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What Is POLST

• A health care providers 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

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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

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Elements of the POLST Paradigm

• Medical order form
• Accompanies patient
• Bright, unique color (Pink in OR, green in WA).
  New ePOLST may not be colored
• Training of professionals
• DNAR orders
• Limit or provide other interventions
• Decisions about transport, ICU, artificial
  nutrition

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If I am unconscious at the last moment then I
dont want any machines or anything.
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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
  life-sustaining 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

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Requirements for a Form Valid

• Patient name
• Resuscitation orders
• Health professional signature and date
• all other information is optionalin Oregon it
  does not require signature of patient
• (verbal orders signed by an RN are acceptable)

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Validation of POLST

• Dunn PM, Schmidt TA et al A method to
  communicate patient preferences about medically
  indicated life sustaining treatment JAGS
  199644785
• Tolle SW, Tilden VP, Nelson CA, Dunn PM A
  Prospective study of the efficacy of the POLST
  JAGS 1998461097
• Lee MA, Brummel-Smith K et al Physician orders
  for life-sustaining treatment (POLST) Outcomes
  in a PACE program JAGS 2000 481-6.

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• Schmidt TA, Hickman SE, Tolle SW, Brooks HSThe
  Physician Orders for Life-Sustaining Treatment
  Program Oregon Emergency Medical Technicians
  Practical Experience and Attitudes JAGS
  2004521430-34.
• Hickman SE, Tolle SW, Brummel-Smith K, Carley MM
  Use of POLST (The Physician Orders for
  Life-Sustaining Treatment Program) in Oregon
  Nursing Facilities JAGS 2004521424-2
• 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 Jul58(7)1241-8.

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Section A Cardiopulmonary Resuscitation (CPR)
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  Section B Medical Interventions
12/29/2020
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Section C Artificially Administered Nutrition
12/29/2020
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Section D DOCUMENTATION OF DISCUSSION
12/29/2020
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Signatures
12/29/2020
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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

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Difficult situations

• Family conflict
• How do you interpret Attempt Resuscitation and
  Limited Interventions?
• Trauma

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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

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• 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
  2004521430-34

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Methods

• Anonymous survey mailed in 2002 to a stratified
  random sample of Oregon paramedics and
  EMT-Intermediates

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Findings

• 572/1048 (55) response rate
• 76 male
• 66 paramedics

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• 73 had treated a patient with a POLST
• POLST, 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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• 25 reported some difficulty finding the form
• 87 were filled out appropriately
• 6 had conflicting orders
• 5 unsigned
• 2 incomplete

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• 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

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Case Study When POLST Works
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Where to keep the POLST

• The front of the chart
• In a red envelop on the fridge (but people do not
  like it)

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The Oregon POLST Registry

• Emergency Medical Services, emergency departments
  and hospital acute care units

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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

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• Over 80,000 forms currently in Registry
• Entering about 3200 new forms/month

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Calls as of January 31, 2012

• 1085 calls
• 335 matches
• 31 match rate

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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

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Users

• Emergency departments 46
• EMS 36
• Acute care 17

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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

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How do I access the POLST Registry?

• Call the 24 hour POLST Registry
• 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
• Date of Birth
• Gender
• Last 4 SSN
• POLST Registry ID
• Home address/residential care facility address
• City, County, or zip code

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What information will be provided?

• Section A and B orders, the date the form was
  signed, and the POLST Registry ID number.
• Hospitals can be faxed the POLST form.
• EMS Confirm your destination hospital and a copy
  can be sent ahead
• THE STAFF ARE NOT MEDICAL PROVIDERS AND CANNOT
  INTERPRETPOLST ORDERS

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Pain Management

• Trick of the trade
• Free IPhone app Opioids

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Equianalgesic dosesof 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

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. . . Changing opioids

• Cross-tolerance
• start with 5075 of equianalgesic dose
• more if pain not well controlled, less if adverse
  effects

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Breakthrough dosing

• Use immediate-release opioids
• 515 of 24-h dose
• Do NOT use extended-release opioids
• Avoid acetaminophen toxicity

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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

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Urticaria, pruritus (no rash)

• Morphine, hydromorphone, usually not fentanyl
• Mast cell destabilization followed by histamine
  release
• Manage with antihistamines or change to fentanyl

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Trick of the tradepain 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)

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Pathophysiology nausea/vomiting
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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!

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Antacids

• H2 receptor antagonists
• cimetidine
• famotidine
• ranitidine
• Proton pump inhibitors
• omeprazole
• lansoprazole
• Misoprostol

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My mother was choking. Called 9-1-1 because her
lips were blueput her on the floor and did CPR.
The medics came and took over. I told them she
had a POLST but I couldnt find itthe form used
to be on the fridge but we got a new one and
hadnt moved it there yet. I that day her
wishes were honored. Daughter of pt   The
daughter was the one who informed first
responders that the patient had a POLST form
which prompted us to call the RegistryAll
life-saving measures were terminated as soon as
orders were announced to honor end of life
wishesThe Registry is a good thing. It is a
stressful time for family and the ability to call
and get the wishes is really helpfulMedic on the
scene
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The pt was very old and in cardiac arrest. There
was a language barrier at the scene and we were
trying to ask the daughter if he had a POLST.
Daughter came back with magnet. Without them the
family the POLST would have never been known to
existoverall, it call to the Registry was
successful. -Medic on the scene
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The pt was very old and in cardiac arrest. There
was a language barrier at the scene and we were
trying to ask the daughter if he had a POLST.
Daughter came back with magnet. Without them the
family the POLST would have never been known to
existoverall, it call to the Registry was
successful. -Medic on the scene
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We had dinner, he was holding the placemats,
and he just went down and collapsed. There was
no eye contact, no voice contact. I called 9-1-1
and my son and daughter-in-law came overasked if
they wanted to override the POLST and we decided
no. This is what he wanted. His wishes were
definitely honored. EMS was professional,
quick, and efficient... The Registry is a
wonderful idea. Should be more publicized so
people know where to put it POLST form -Wife
of pt
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The Oregon POLST Registry

• Emergency Communication Center at OHSU
• 503 494-7333 (MRH)
• 888 476 5787 (1-888 4-POLSTS)
• E-mail polstreg_at_ohsu.edu
• Website
• http//www.ohsu.edu/polst/programs/OregonPOLSTRegi
  stry.htm

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POLST Information

• Center for Ethics in Health Care, OHSU
• 503 494-3965
• Fax [phone]
• Ethics_at_ohsu.edu
• www.polst.org