Prehospital Providers’ Perspectives about Online Medical Direction in Emergency End-of-Life Decision-Making

Waldrop, Deborah P.; Waldrop, Michael; McGinley, Jacqueline M; Crowley, Charlotte R; Clemency, Brian M.

doi:10.1080/10903127.2020.1863532

Cited by 8 publications

(5 citation statements)

References 20 publications

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“…In general, paramedics tended to call the base hospital physician more when not transporting a patient. This is similar to the use of online medical oversight for informed refusals [17][18][19]. Overall, this underscores the necessity that base hospital physicians should be well versed in the POLST, as well as with end of life care symptom management and goals of care communication in order to provide paramedics support.…”

Section: Discussionmentioning

confidence: 73%

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

et al. 2022

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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.

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Section: Discussionmentioning

confidence: 73%

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

et al. 2022

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“…28 The study finding that 68% of cases involved some type of remote clinical consultation highlights the important role that remote clinical support can have in mitigating risk, especially for non-conveyance when goals of care are absent or unclear. 30 Research has also shown that paramedics are positively inclined to confer with a paramedic colleague, especially if they have a pre-existing professional relationship. 31 While this study did not investigate the nature of the phone consults, it is possible that the ability to contact a paramedic specialist gave paramedics additional confidence to leave patients at home following clinical care.…”

Section: Discussionmentioning

confidence: 99%

Characteristics and paramedic management of patients enrolled in a novel assess, see, treat and refer palliative care clinical pathway: A retrospective descriptive cohort study

Johnston,

Armour,

Muinoi

et al. 2023

Paramedicine

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Introduction Patients with palliative care needs seek support from paramedics in instances of unexpected worsening of symptoms associated with their primary diagnosis, but often do not desire conveyance to an emergency department. Despite this, up to one-quarter of patients with palliative care needs will experience an avoidable admission to the emergency department. British Columbia Emergency Health Services, in collaboration with Canadian Virtual Hospice and regional health authorities, developed the Palliative Care Assess, See, Treat and Refer (ASTaR) Clinical Pathway, with palliative clinical practice guidelines and education to support paramedics minimising avoidable admissions to emergency departments. Aim To describe the paramedic management of patients enrolled in the palliative care ASTaR clinical pathway, supported by paramedic-specific education and clinical practice guidelines. Methods This study was a retrospective descriptive cohort study of the first 100 patients enrolled by paramedics in the palliative care ASTaR clinical pathway following its introduction in October, 2019. Results The median age of patients was 78 years (IQR 70–88), they were more often male ( n = 58) and in a private residence at the time of 911 call ( n = 91). Calls for assistance were in the work week ( n = 73), but often out of business hours ( n = 61). Primary care paramedics provided the majority of care ( n = 64), most frequently contacting paramedic specialists for clinical advice ( n = 32, 47%). The most common patient complaints were dyspnoea ( n = 25), altered conscious state ( n = 16), mobility assistance ( n = 14), and pain ( n = 13), with pharmaceutical intervention required in less than half of cases. Conclusion Paramedics continue to play a critical role in supporting patients with palliative care needs, particularly during out-of-hours periods. When supported by robust clinical practice guidelines and integrated systems of care, this cohort study demonstrates that paramedics may be able to manage the requirements of patients with palliative care needs and their family, friends, and carers, beyond clinical care and conveyance.

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“…Vielen Ärzten fehlt das nötige Selbstvertrauen, ToR-Entscheidungen zu treffen. Einige berichten, dass sie nichtvalidierte oder kontroverse Faktoren als einzigen Grund für die Beendigung der Wiederbelebung verwenden [114,115,[120][121][122][123][124][125][126][127][128][129][130]. Die Entscheidungsfindung wird im Kontext neuerer erweiterter Wiederbelebungstechniken noch komplexer.…”

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Ethik der Reanimation und Entscheidungen am Lebensende

Mentzelopoulos

Couper

Voorde³

et al. 2021

Notfall Rettungsmed

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Diese Ethikleitlinien des Europäischen Rats für Wiederbelebung enthalten evidenzbasierte Empfehlungen für die ethische, routinemäßige Praxis der Wiederbelebung und für die Betreuung von Erwachsenen und Kindern am Lebensende. Die Leitlinie konzentriert sich in erster Linie auf wichtige Maßnahmen in Bezug auf ethische Praktiken (d. h. Patientenverfügung, vorausschauende Behandlungsplanung* und gemeinsame Entscheidungsfindung), die Entscheidungsfindung in Bezug auf Wiederbelebung, Ausbildung und Forschung. Diese Bereiche stehen in engem Zusammenhang mit der Anwendung der Prinzipien der Bioethik in der Praxis der Wiederbelebung und der Betreuung am Lebensende. Zusatzmaterial online Zusätzliche Informationen sind in der Online-Version dieses Artikels (10.1007/s10049-021-00888-8) enthalten.

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Prehospital Providers’ Perspectives about Online Medical Direction in Emergency End-of-Life Decision-Making

Cited by 8 publications

References 20 publications

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

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

Characteristics and paramedic management of patients enrolled in a novel assess, see, treat and refer palliative care clinical pathway: A retrospective descriptive cohort study

Ethik der Reanimation und Entscheidungen am Lebensende

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