Henry Ledo, a paramedic in Contra Costa County for more than 16 years, has answered more 911 calls than he can count. Resuscitating patients is a routine part of his work.
“So many times, I get on scene and the person is not breathing and doesn’t have a pulse,” he says. “We are sticking tubes down your throat and breathing for you. To get your heart pumping and blood circulating, we’re compressing the chest.” It’s common for ribs to break and the sternum to fracture during compressions. It’s only once reaching the hospital, after the trauma is inflicted, that paramedics discover whether or not the patient wanted to be resuscitated.
“It’s a beautiful thing when you’ve resuscitated someone and you get them back,” Ledo says, “but if you can do anything for anyone in their life, it’s at least to respect their wishes.”
Respecting last wishes is about to get easier. Spurred by a 2015 state law, a coalition of emergency and social service providers in Alameda, Contra Costa and San Diego Counties are creating an electronic registry of Physician Orders for Life-Sustaining Treatment (POLST) forms.
These forms, currently printed on bright pink paper, are used by seriously ill patients who want to clearly declare how much medical care they want in an emergency. People may not be able to communicate because they’re having a heart attack, a stroke, or have dementia, for instance.
This form delineates what extraordinary measures should be taken (or not taken), such as performing CPR or administering a feeding tube. Many adults have “advance directives,” legal documents that designate a surrogate decision-maker and spell out health preferences. But POLST forms go further, creating a set of medical orders that are signed by the provider and the patient that travel with the patient. A 2011 Oregon study found that people with advanced illness or frailty who had a POLST form had their end-of-life treatment wishes honored 94 percent of the time.
In the electronic registry, to go online in early 2018, POLST forms will be submitted, stored and retrieved from the web-based portal so information can be easily shared between health care organizations, community-based physicians, community clinics, nursing homes and hospice agencies.
Pat Frost is the director of emergency medical services for the local EMS authority in Contra Costa County, which will participate in the program. “We haven’t traditionally been able to exchange data with hospitals or to link to the hospital records,” she says.
In 2015, the Contra Costa County EMS recorded 94,278 responses; it employs about 1,000 emergency medical technicians and slightly more than 400 paramedics.
Evan Seevak, a geriatrician for 17 years who was an ambulance driver before he went to medical school, is looking forward to seeing the POLST system in action. He spends time with patients to determine their end-of-life care treatment preferences. “Because I’m a geriatrician I try to do a good job documenting people’s wishes…and many people want to have a conversation with their family, which is good, so they are all on board.”
Seevak, also an administrator at the Alameda Health System, understands the need to honor a dying person’s wishes from personal experience, too. “I had a really horrible personal experience with my Dad, who had very clearly documented what he didn’t want—to be resuscitated,” says Seevak. “He died of a heart attack, but ended up getting enormous amount of care and dying in a hospital ICU even though that was clearly not what he wanted.”
As an emergency room physician at Highland Hospital in Oakland for 30 years, David English says there are many problems with paper POLST forms that the electronic registry will ease. For one, POLST forms are often photocopied in hospitals onto black-and-white paper, which means they don’t stand out like the originals printed on pink cardstock. And often the people who have the forms at home tuck them inside folders or even in safe deposit boxes instead of tacking them to the refrigerator or somewhere visible, as recommended.
“To have [these forms] readily stored and available is profoundly appealing,” says English, “We have many folks who are very frail for whom a fierce resuscitation effort isn’t the best thing for them, but if we don’t know, we have to preserve their chance at staying alive.”