By William Koenig
The Daily News of Los Angeles
LOS ANGELES — It’s a story I hear all too often. Paramedics are called to an emergency situation at someone’s home and find a frail senior in cardiac arrest. The family members are unable to find their loved one’s advance directive or do not resuscitate order, a DNR, and the patient cannot communicate his or her wishes.
A recent study in the New England Journal of Medicine found that 1 in 4 elderly Americans will eventually need someone to make a crucial decision about their end-of-life treatment.
As director of Emergency Medical Services for Los Angeles County, I am not surprised by this finding. It’s all too common for elderly or sick patients to become incapacitated, and unable to speak for themselves at the end of life.
That’s why it’s so important to talk with family members and other caregivers about end-of-life treatment preferences, and to clearly define one’s wishes. Undoubtedly, this isn’t easy. Confronting death may be the hardest thing for a sick or elderly person to do, and it’s just as hard for their family. Calling 911 may initiate events over which patients and their families feel they have little control.
Too often, a patient’s wishes are known but not put in writing. Even with a written document, a recent review in Los Angeles revealed that many families cannot locate it when most needed. Family members know the patient’s desires, and can communicate them, yet policies create confusion and difficult situations for medical professionals responding to emergency calls.
In response to these problems, both the state of California and L.A. County have implemented new policies designed to help ensure patients’ end-of-life wishes are honored. In 2007, the L.A. County EMS system implemented a new resuscitation policy developed in partnership with the University of California, Los Angeles — that allows EMTs to forgo resuscitation if a family member on the scene verbally requests DNR in accordance with a patient’s wishes. Prior to the new policy, EMTs could only forgo resuscitation in the event of irreversible death or if presented with a written DNR. Unfortunately, that sometimes resulted in resuscitation efforts that ran counter to a patient’s wishes, as well as the paramedics’ best judgment.
A recent study of the new EMS verbal DNR policy, conducted on behalf of the California HealthCare Foundation, shows the new policy is helping, with a small but meaningful reduction in attempted resuscitations when a family member conveys the patient’s request. Importantly, EMS personnel reported satisfaction with the new guidelines, and there were no reports of adverse consequences. In a series of focus groups conducted among EMS personnel, several paramedics spoke about how the new policy encourages improved communication with family and other caregivers, “which can make their experience at least a bit less traumatic.”
A new state policy has the potential to make an even bigger difference. Implemented in 2009, POLST (Physician Orders for Life-Sustaining Treatment), is a physician order that gives patients more control over their end-of-life care. As the first universal medical order that is honored across care facilities, POLST has significantly changed the landscape in how end-of-life treatment is provided.
Different from an advance directive, POLST is signed by both the physician and patient, and specifically identifies the types of medical treatment that a patient wishes to receive toward the end of life.
POLST is more than just a form. It’s a tool that provides a framework for end-of-life care conversations between patients, their families and their providers.
When EMS providers are called to a house or nursing home where a patient has a POLST form, we know exactly what the patient wants or doesn’t want in terms of treatment. This makes our job easier, and helps to ease the strain on families already confronting a stressful and emotional situation.
William Koenig is director of Emergency Medical Services for Los Angeles County.
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