POLST, MOLST, and “Don’t Do CPR on My Mom”
NOTE: THIS IS SPECIFIC TO MAINE EMS PROVIDERS ONLY; however, if you are not a MEMS licensed provider, this information is still important for you. You just need to interpret it based on your local laws, regulations, and protocols.
At 3 am, you respond to a nursing home for a 57 year old in severe respiratory distress. On arrival, the nurse presents you with a form entitled “Physician Orders for Life Sustaining Treatment” (POLST). As you are reviewing this, the patient goes into cardiac arrest. The POLST form clearly spells out that this patient would allow CPAP for respiratory distress, would allow IV fluids, but would not allow chest compressions, medications, or ventilatory support. It does not say “DNR” in big letters across the top or “Approved by Maine EMS” anywhere on the document. Can you respect this document?
As the medical community does a better job of respecting patient autonomy, and as more individuals are aware of the concept of end-of-life care, medical providers, patients, attorneys, and advocacy groups are working together to improve patients’ end-of-life care. Decisions and documentation of those decisions is being formalized. There is a gap in belief and action about end-of-life decisions; about 70% of people believe end of life planning is important, only about a third of Americans have a living will (36 percent) and 37 percent have identified a healthcare proxy or drawn up a durable power of attorney for healthcare. However, this is an important topic for most Americans.
Historically, the medical community and EMS have been suspicions of the concept of DNR. Working from the principle of “First do no harm,” there has long been an assumption that maximizing quantity of life was the greatest benefit to a patient; quality of life was felt to be of secondary importance and patient autonomy during life threatening events was occasionally given nothing more than lip service. In addition, there was (and persists, to a limited degree) paranoia that patient family members might have evil motives for descalating care. When the concept of DNR was introduced to EMS, therefore, it was with the caveat that the default behavior was resuscitation and only the most rigorous, state EMS approved, “i” dotted and “t” crossed DNR forms were to be grudgingly respected.
This attitude has evolved dramatically over the last decade, although this past summer’s discussion of “death panels” makes it clear that there is still a lot of education needed. Patient autonomy and consciousness about quality of life often being more important than quantity of life has driven many to do a better job discussing what needs to be done during emergency situations, particularly when the patient has lost decision making capacity. During this transition phase, there have been some excellent and some not so good attempts to clarify patient wishes. Some are absolutely clear while others vary between containing so little information as to be worthless and being so detailed that clinicians can’t find specific information about, say, cardiac arrest. Standardization of language and documentation has generally improved the usefulness of these documents. Nonetheless, EMS is still in the catch-up phase and transitioning from a mindset of “first resuscitate” to “first follow the patient’s wishes” is difficult.
Maine EMS, through the statewide protocols, has addressed the issue of valid DNR orders. Page 1 of the Gray section of the 2008 Protocols is “Do Not Resuscitate.” Item “I” clarifies when to start resuscitation. Section “II” discusses when not to start resuscitation. Section IIC addresses DNRs and reads as follows (my comments are inserted between the “*{}*” brackets):
When a physician Do Not Resuscitate (DNR) order is presented in one of three forms:
1. EMS DNR orders from other state EMS/DNR programs. If the order or device (e.g., plastic bracelet, jewelry, or card) appear to be in effect, and understandable to the crew, follow the order’s specific instructions. If there are no specific instructions beyond “DNR”, follow Maine EMS Comfort Care/ DNR Guidelines.
*{Since we have so many out-of-staters, it’s important to respect their wishes}*
2. Non-EMS DNR Orders - A written DNR order executed by a patient’s personal physician should be honored if it is understandable to the crew and if it is dated within 1 (one) year. Follow the order as written. If it is non-specific as to care to provide or withhold, follow the MEMS Comfort Care/DNR guidelines.
*{This is the key. If a DNR order executed by the patient’s physician is understandable and is dated within 1 (one) year, you honor it. It can be folded into origami. It can be written on a stone tablet. It can be red, blue, green, white, pink, or any color. It does not have to say “Approved by Maine EMS.” As long as there is a DNR order, executed by the patient’s physician and dated within ine year, follow the order as written. Note also that these orders don’t have to be limited to DNR. They can outline comfort care, allowable interventions, and other areas of impact on EMS. If there are conflicts with the protocols, contact medical control.}*
3. Maine EMS Comfort Care / DNR Program - A Maine EMS Comfort Care/ DNR order does not have an expiration date. Once activated, it remains in effect until the patient or someone acting on their behalf as described and authorized on the Comfort Care/DNR form cancels it. (Note: Although no longer distributed by Maine EMS, extant DNR/Comfort Care “orange” forms, wallet cards and plastic bracelets remain valid.)
One additional really important point is that the patient is the decision maker. If the patient has decision making capacity, then the patient’s wishes overrules anything written, anything the healthcare POA says, any other source of information. Be respectful of these other documents and decision makers, but the patient has the final say.
So, going back to the original scenario, what do you do? The POLST form, if its intention is clear and is dated within the past year, is a valid DNR under Gray IIC2. You respect it and follow the orders. If there is a treatment that conflicts with protocols, talk to medical control. But remember, respecting the patients’ wishes is critical, especially during the highly stressful times in which a DNR would be considered.
It’s worth your time to look at www.polst.org for more information.
Take care, do good, and remember, we help people achieve quality and dignity in life and and in death.
References:
Brandon E. “Planning Your End-Of-Life Care: Why filling out the paperwork isn’t enough. US News and World Report. September 14,2009. Accessed from http://www.usnews.com/money/personal-finance/retirement/articles/2009/09/14/planning-your-end-of-life-care.html 10/20/09.
www.polst.org Accessed 10/20/09.
January 4th, 2010 at 8:07 pm
A sensible approach. I was lucky in that as a new EMT in 1989 our ALS was provided by our local doc, Tony Garland. He approached codes and critical calls with pragmatism and sensitivity. That was the approach I adopted, and now common sense has become official in our state, I guess.