My grandfather should have died at least four times. Between 92 and 94 years old, he had cancer, chronic pneumonia, and a full-bypass heart surgery (I think I’m forgetting something). He was like one of those blow-up clowns that gets knocked down but keeps springing back up. He was waiting for my grandmother to die first: In the ultimate act of romantic devotion, he followed her to the grave 10 days later, on the same afternoon as her final mourners’ prayer service. Where Lucia was, Israel wanted to be.
My mother tells me that when Gramps was transported by ambulance to a major hospital in Northridge, just north of Los Angeles, he carried a form, signed by his physician, to present to the receiving care team. This form, called a POLST (for Physician’s [or Portable] Orders for Life-Sustaining Treatment) is legally binding and meant to instruct emergency responders about the patient’s wishes in case the worst happens. Basically it tells them whether to resuscitate if no pulse is found and, if a pulse is found, what sort of medical interventions to provide.
But something went wrong. Someone didn’t want to accept my grandfather’s POLST form. Whether it was outdated or improperly completed, I cannot say. Although the matter worked itself out, it was avoidable and traumatic to all involved. The experience drove home for me two realities of palliative care:
1) Immediate access to a definitive account of the patient’s wishes (whether provided directly by the patient or through a surrogate/proxy) can avoid confusion during critical moments when emotions are frazzled; and
2) The pervasive model of placing the POLST ID number on the refrigerator door—like the old “Vial of Life” decals designed for reference by responders more than 35 years ago—is no longer sufficient because a combination of factors (e.g., earlier disease detection and more advanced mobility tools) have improved patients’ longevity and quality of life. This often lets them avoid being bedridden (a good thing) and live longer. Conversely, they are more likely to suffer a medical crisis while out and about. During a medical crisis the first call won’t be to a state POLST registry or the next of kin. It will be to 9–1–1, so responders need all the data they can get.
As described by Steven Boughey, division chief for EMS at Tualatin Valley Fire & Rescue in Oregon, today’s cardiac arrest workflow involves stepping away from critical patients to inquire of an emergency communications center as to whether they have a POLST. Abby Dotson, PhD, director of the Oregon POLST Registry, agrees getting better information to EMS crews while they are at the patient’s side is vital to maximizing their chances of saving lives—or letting a person pass away in dignity, spared the pain of broken ribs if he or she is ready to say good-bye.
But getting information about a patient’s POLST to their fire or EMS crew is only half the battle. We have an obligation to facilitate completion of POLST forms in the first place by making it easier for primary caregivers and caregivers of all stripes to talk with their patients about end-of-life-wishes and facilitate their getting the forms filled out quickly and correctly. Beyond Lucid Technologies, building on a decade developing software solutions for prehospital care, was honored to win the Oregon POLST Registry’s contract to revitalize and modernize its core tech, adding in time-saving features like optical character recognition to speed form completion. We are excited to make this announcement on the heels of the 2019 Oregon EMS Conference, at which POLST was a major topic of discussion.
OPR will leverage the Beacon Prehospital Health Information Exchange to intake forms while sharing stored ones with caregivers who require them. These same “prehospital pipes” will allow any EMS charting system to query the Oregon POLST Registry in real-time via API, from within its own ePCR, ensuring the patient is treated in accordance with his or her wishes.