Paramedic use of the Physician Order for Life-Sustaining Treatment (POLST) for medical intervention and transportation decisions

Abstract

Background Physician Order for Life-Sustaining Treatment forms (POLST) exist in some format in all 50 states. The objective of this study is to determine paramedic interpretation and application of the California POLST for medical intervention and transportation decisions. Methods This study used a prospective, convenience sample of California Bay Area paramedics who reviewed six fictional scenarios of patients and accompanying mock POLST forms. Based on the clinical case and POLST, paramedics identified medical interventions that were appropriate (i.e. non-invasive positive pressure airway) as well as transportation decisions (i.e. non-transport to the hospital against medical advice). EMS provider confidence in their POLST interpretation was also assessed. Results There were 118 paramedic participants with a mean of 13.3 years of EMS experience that completed the survey. Paramedics routinely identified the selected medical intervention on a patients POLST correctly as either comfort focused, selective or full treatment (113-118;96%-100%). For many clinical scenarios, particularly when a patient’s POLST indicated comfort focused treatment, paramedics chose to use online medical oversight through base physician contact (68-73;58%-62%). In one case, a POLST indicated “transport to hospital only if comfort needs cannot be met in current location”, 13 (14%) paramedics elected to transport the patient anyway and 51 (43%) chose “Non-transport, Against Medical Advice”. The majority of paramedics agreed or strongly agreed that they knew how to use a POLST to decide which medical interventions to provide (106;90%) and how to transport a patient (74;67%). However, after completing the cases, similar proportions of paramedics agreed (42;36%), disagreed (43;36%) or were neutral (30;25%) when asked if they find the POLST confusing. Conclusion The POLST is a powerful tool for paramedics when caring patients with serious illness. Although paramedics are confident in their ability to use a POLST to decide appropriate medical interventions, many still find the POLST confusing particularly when making transportation decisions. Some paramedics rely on online medical oversight to provide guidance in challenging situations. Authors recommend further research of EMS POLST utilization and goal concordant care, dedicated paramedic POLST education, specific EMS hospice and palliative care protocols and better nomenclature for non-transport in order to improve care for patients with serious illness.

Prehospital emergency medicine for children receiving palliative home care in Germany—a cross-sectional, exploratory study of EMS providers

“…It was observed across all three levels of German EMT education. The interviews in this study revealed similar findings to those of Breyre regarding emotional overload ( 25 , 26 ); however, our study revealed a significantly greater emotional burden in emergencies involving children with life-limiting conditions.…”

“…An important part of the future guideline is to inform the participants about the importance and the limitations of decision making. DNR orders or Physician Order for Life-Sustaining Treatment (POLST) forms can help in making these decisions ( 26 ). In a qualitative study on a group of 15 EMTs and paramedics, the participants stated that formal training was needed to better prepare them for the emotional aspects of communicating with patients and their families, to handle grief, and to obtain advice in decision making ( 25 ).…”

Implementation and evaluation of a palliative care training unit for EMS providers

“…If CPR is not contraindicated and the parents don’t disagree, then advanced life-support (ALS) should be started until the EMS team gets new information. DNR orders or Physician Orders for Life-Sustaining Treatment (POLST) forms can help the EMS make decisions ( 43 ).…”