EMS and Advanced Care Planning

EMS workers now have an opportunity to help patients execute their end-of-life medical wishes through POLST.

“At the national level, it is simply called Portable Medical Orders, or POLST for short,” says Kim Callanan, executive director, National POLST. “Portable means the order is valid outside the clinic or doctor’s office. This allows the results of the decisions a patient has made via a quality shared decision-making conversation they have had about goals of care with their care team to follow them across care settings.”

POLST Primer

POLST is a process and a form that goes by different names in different states. As a process, POLST is part of advance care planning, “which helps you live the best life possible,” Callanan notes. An additional part of the process is a conversation with the medical provider about one’s medical condition, treatment options, goals of care and wishes.

POLST also is a medical order form that travels with a person.

“POLST communicates your wishes as medical orders. A POLST form tells all health care providers during a medical emergency what you want: take me to the hospital or I want to stay here; yes, attempt CPR or no, don’t attempt CPR; these are the medical treatments I want, this is the care plan I want followed,” Callanan notes.

POLST gives seriously ill or frail people more specific direction over their health care treatments compared to advance directives and more options than do not resuscitate (DNR) orders, Callanan points out.

“Our wishes for treatments and care we do and do not want tend to change as we become more seriously ill vs. when we are healthy,” Callanan notes. “POLST complements advance directives. Advance directives only come into play when a patient can no longer speak for themselves. POLST, as a transportable medical order set, begins providing direction to clinicians upon completion.”

Addressing what EMS workers should know about POLST and the importance of their role in advance care planning, Callanan says EMS workers should understand how POLST can help them know a patient’s values and wishes, enabling them to provide goal-concordant care.

“This means providing the care patients want and not using treatment options patients do not want,” she adds. “Explaining care and treatment to a patient is a large part of EMS work. POLST can make that easier. Envision it as an outline about treatments and care settings to talk about with their patients.”

Starting the Difficult Conversation

EMS workers are often trusted community members, Callanan points out.

“Particularly in rural communities, they may know their patients quite well before they even are called to their homes,” she adds. “When in a patient’s home, they have an opportunity to talk with patients about what matters most to them in managing this course of advancing serious illness. They can ask about POLST and advance directives and help patients through the completion process.”

National POLST is involved in a research project—funded by the Rita and Alex Hillman Foundation—to bring the word out about how POLST can help patients facing serious, advancing illnesses and frailty, says Callanan. “[The project] is focused on people in rural areas, as we agreed [that] novel approaches that go beyond expecting their doctor solely to talk about advance care planning just was not enough,” says Callanan.

The initial step had been to identify an advanced practice nurse who is often a primary information source in rural areas where a physician is not easily accessible.

“As we studied further, we found that EMS workers had a natural community connection and were seen as trusted care providers,” Callanan says. “EMS workers were found to often have frequent contact with their patients and subsequently could influence how they dealt with serious, progressive illnesses just by having meaningful shared decision-making conversations.”

POLST has developed a pilot program bringing together people in government, local organizations, care providers and EMS professionals.

“We have listening sessions where we take their input about how we can all work together to improve knowledge about completing advance care planning and POLST,” Callanan says. “Then we design and implement innovations to get the word out, including education for EMS workers and printed patient materials and support from the local and state POLST organization.”

Expanding Pilot Programs

EMS workers can avail themselves of their state’s information about how POLST and advance care planning work together to help their patients by reviewing their state and/or the national POLST website at polst.org, Callanan says.

“Then if they can consider how their treatment approaches with patients could introduce these important concepts, it will benefit them and their patients considerably,” she adds.

The grant-funded project includes pilot programs in Maine, Virginia and Hawaii.

“Information from these pilots will be shared across the states through our national information-sharing approach created and managed at National POLST,” she says. “If EMS workers have checked in with and/or joined their state POLST organization, they will get information about what we have learned and find out about best approaches for this important work.”

In Maine, Kandyce Powell, Maine Hospice Council and Center for End of Life Care executive director, notes the organization has developed a significant amount of diverse programming, addressing access to quality end-of-life and palliative care across all settings, focusing for many years on underserved and disenfranchised populations.

Powell notes Maine is a large state comprised of many highly rural areas that often does not even have adequate broadband coverage and has health care access challenges.

POLST as Standard of Care

Powell—who has been involved in several think tanks focusing on why advanced care planning hasn’t worked as well as anticipated—connected with National POLST and started formally introducing it to Maine’s medical and health care community.

“We started off by getting the attorney general's office involved with us in conversation,” says Powell. “We were asked to be the administrative home for POLST in Maine.”

Powell and her team sought to make POLST a standard of care that all health care providers and prescribers would recognize as integral and important to their goals of care conversations with appropriate patients who might have a limited life expectancy, as opposed to an acute illness with short-term recovery or even a chronic illness with potential recovery.

“It is a conversation that precedes filling out a form in conjunction with your designated health care provider,” she adds. “It takes the patient and family—and by ‘family’ I mean the network of support such as the guardian or durable health care power of attorney—to discuss the patient’s care goals and walk them through the elements of a POLST form so they will understand their available care options. Then they can decide which ones might be consistent with their own values as a human being and values for them as they deal with their own illness.”

That includes gaining clarity on what a DNR and CPR means, helping the patient make an informed decision that is consistent with their own value of health and well-being, even if they're physically ill, notes Powell.

“We identified how key the paramedicine community is to our highly rural areas,” notes Powell. “We in our organization and with the POLST initiative want our emergency technicians and our health care providers to also be as comfortable and knowledgeable themselves about what resources are available that might be helpful to their patients and families and also to themselves. Our paramedics are often an integral part of keeping people at home in highly rural areas.”

Carol Brzozowski is a frequent contributor to EMS World.