The Oregon physician orders for life-sustaining treatment registry: a preliminary study of emergency medical services utilization.

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. To determine if Emergency Medical Technicians (EMTs) can use the Oregon POLST Registry to honor patient preferences. 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. 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. 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.

Schmidt TA ，Olszewski EA ，Zive D ，Fromme EK ，Tolle SW ... -  《JOURNAL OF EMERGENCY MEDICINE》

The Physician Orders for Life-Sustaining Treatment program: Oregon emergency medical technicians' practical experiences and attitudes.

To evaluate emergency medical technicians' (EMTs) experiences with the Physician Orders for Life-Sustaining Treatment (POLST) program and learn about attitudes regarding its effectiveness. Anonymous survey mailed to a stratified random sample. Tri-County Portland, Oregon, area. A total of 572 Oregon EMT respondents (out of 1,048 surveys) were included in the analysis. Survey questions about experiences with the POLST form and opinions about POLST. Respondents were mostly male (76%) and paramedics (66%). Most respondents (73%) had treated a patient with a POLST, and 74% reported receiving education about POLST. EMTs reported that POLST, when present, changed treatment in 45% of cases. Seventy-five percent of the respondents agreed that the POLST form provides clear instructions about patient preferences, and 93% agreed that the POLST form is useful in determining which treatments to provide when the patient is in cardiopulmonary arrest. Fewer (63%) agreed that the form is useful in determining treatments when the patient has a pulse and is breathing. Most respondents have experience with the POLST program. EMTs find the POLST form useful and often use it to change treatment decisions for patients.

Schmidt TA ，Hickman SE ，Tolle SW ，Brooks HS ... -  《JOURNAL OF THE AMERICAN GERIATRICS SOCIETY》

Physician orders for life-sustaining treatment (POLST): lessons learned from analysis of the Oregon POLST Registry.

Physician Orders for Life-Sustaining Treatment (POLST) has become a common means of documenting patient treatment preferences. In addition to orders either for Attempt Resuscitation or Do Not Attempt Resuscitation, for patients not in cardiopulmonary arrest, POLST provides three levels of treatment: Full Treatment, Limited Interventions, and Comfort Measures Only. Oregon has an electronic registry for POLST forms completed in the state. We used registry data to examine the different combinations of treatment orders. We analyzed data from forms signed and entered into the Oregon POLST Registry in 2012. The analysis included 31,294 POLST forms. The mean Registrant age was 76.7 years. 21,396 (68.4%) had Do Not Attempt Resuscitation (DNR) orders and 9900 (31.6%) had orders for "Attempt Resuscitation". The 6 order combinations were: Do Not Resuscitate (DNR)/Comfort Measures Only 10,769 (34.4%), DNR/Limited Interventions 9306 (29.7%), DNR/Full Treatment 1211 (3.9%), Attempt Cardiopulmonary Resuscitation (CPR)/Comfort Measures Only 11 (0.04%), Attempt CPR/Limited Interventions 2281 (7.3%), and Attempt CPR/Full Treatment 7473 (23.9%). The most common order combinations were DNR/Comfort Measures Only, DNR/Limited Interventions and Attempt Resuscitation/Full Treatment. These three makes sense to health professionals. However, other order combinations that require interpretation at the time of a crisis were completed for about 10% of Registrants. These combinations need further investigation.

Schmidt TA ，Zive D ，Fromme EK ，Cook JN ，Tolle SW ... -  《-》

Concordance of out-of-hospital and emergency department cardiac arrest resuscitation with documented end-of-life choices in Oregon.

Resuscitation measures should be guided by previous patient choices about end-of-life care, when they exist; however, documentation of these choices can be unclear or difficult to access. We evaluate the concordance of a statewide registry of actionable resuscitation orders unique to Oregon with out-of-hospital and emergency department (ED) care provided for patients found by emergency medical services (EMS) in out-of-hospital cardiac arrest. This was a retrospective cohort study of patients found by EMS providers in out-of-hospital cardiac arrest in 5 counties in 2010. We used probabilistic linkage to match patients found in out-of-hospital cardiac arrest with previously signed documentation of end-of-life decisions in the Oregon Physician Orders for Life-Sustaining Treatment (POLST) registry. We evaluated resuscitation interventions in the field and ED. There were 1,577 patients found in out-of-hospital cardiac arrest, of whom 82 had a previously signed POLST form. Patients with POLST do-not-resuscitate orders for whom EMS was called had resuscitation withheld or ceased before hospital admission in 94% of cases (95% confidence interval [CI] 83% to 99%). Compared with patients with no POLST or known do-not-resuscitate orders, more patients with attempt resuscitation POLST orders had field resuscitation attempted (84% versus 60%; difference 25%; 95% CI 12% to 37%) and were admitted to hospitals (38% versus 17%; difference 20%; 95% CI 3% to 37%), with no documented misinterpretations of the form once CPR was initiated. In this sample of patients in out-of-hospital cardiac arrest, out-of-hospital and ED care was generally concordant with previously documented end-of-life orders in the setting of critical illness. Further research is needed to compare the effectiveness of Oregon's POLST system to other methods of end-of-life order documentation.

Richardson DK ，Fromme E ，Zive D ，Fu R ，Newgard CD ... -  《-》

Use of the Physician Orders for Life-Sustaining Treatment program in Oregon nursing facilities: beyond resuscitation status.

Program was designed to communicate resident/surrogate treatment preferences in the form of medical orders. To assess statewide nursing facility use of the Physician Orders for Life-Sustaining Treatment (POLST) and to identify the patterns of orders documented on residents' POLST forms. Telephone survey; on-site POLST form review. Oregon nursing facilities. One hundred forty-six nursing facilities in the telephone survey; 356 nursing facility residents aged 65 and older at seven nursing facilities in the POLST form review. A telephone survey; onsite POLST form reviews. In the telephone survey, 71% of facilities reported using the POLST program for at least half of their residents. In the POLST form review, do-not-resuscitate (DNR) orders were present on 88% of POLST forms. On forms indicating DNR, 77% reflected preferences for more than the lowest level of treatment in at least one other category. On POLST forms indicating orders to resuscitate, 47% reflected preferences for less than the highest level of treatment in at least one other category. The oldest old (> or = 85, n=167) were more likely than the young old (65-74, n=48) to have orders to limit resuscitation, medical treatment, and artificial nutrition and hydration. The POLST program is widely used in Oregon nursing facilities. A majority of individuals with DNR orders requested some other form of life-extending treatment, and advanced age was associated with orders to limit treatments.

Hickman SE ，Tolle SW ，Brummel-Smith K ，Carley MM ... -  《JOURNAL OF THE AMERICAN GERIATRICS SOCIETY》