Sylvia Feder, MA, MICP; Roger L. Matheny, MICP; Robert S. Loveless, PhD, EMT-D; Thomas D. Rea, MD, MPH
Feder S, Matheny RL, Loveless RS, Rea TD. Withholding Resuscitation: A New Approach to Prehospital End-of-Life Decisions. Ann Intern Med. 2006;144:634-640. doi: 10.7326/0003-4819-144-9-200605020-00006
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Published: Ann Intern Med. 2006;144(9):634-640.
Emergency medical services (EMS) personnel attending out-of-hospital cardiac arrests sometimes attempt to resuscitate patients who do not want life-sustaining measures.
This study involving 2770 patients with EMS-attended cardiac arrests assessed outcomes of guidelines that permitted personnel to withhold resuscitation in patients with terminal illnesses when the patients or caregivers indicated, in writing or verbally, that they did not want resuscitation. Sixteen of 35 EMS agencies in King County, Washington, implemented the guidelines. Implementation and control agencies withheld resuscitation in approximately 11.8% and 5.3% of cardiac arrests, respectively. The difference was primarily due to honoring verbal requests.
In this observational study, self-selected agencies volunteered to implement guidelines.
“Participating agencies” were defined as those that agreed to implement the 1998 guidelines. “Nonparticipating agencies” were those that did not implement the guidelines. DNR = do not resuscitate; EMS = emergency medical services.
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Assoc. Prof, Dept. of Fam Med, University of Washington, Chair, WSMA EOL Consensus Coalition
May 23, 2006
To the Editor: The recent article on "Withholding Resuscitation: A New Approach to Prehospital End-of-Life Decisions" by Feder et al describes an observational study started in King County, WA in 1998, and made reference to a specific, state-approved prehospital DNR order form. Since this study began, Washington replaced this form with the (Physician Orders for Life-Sustaining Treatment) POLST form. The accompanying editorial by Kellerman and Lynn describes the value of the POLST form as an example of an increasingly widespread standard form for seriously ill persons to document their treatment wishes as physician orders. POLST originated in Oregon and research has demonstrated its effectiveness in helping patients have their preferences for end-of-life care honored, even when EMS is contacted .
Encouraged by the success of the POLST program in Oregon, the Regional Ethics Network of Eastern Washington (RENEW) adapted the form for use in Washington State. The Washington State Medical Association (WSMA), the Department of Social and Health Services (DSHS) and the Washington State Dept of Health (DOH) approved a pilot of the POLST in two counties in Eastern Washington in 2000. Based on the results of that pilot , the DOH replaced the previously approved prehospital DNR order form with the POLST in 2001. Educational and promotional efforts have been ongoing. These include: DOH training for EMS responders in all counties in the state; WSMA publications and workshops targeting physicians as well as providing a POLST video and tools on its website ; the Association of Washington Public Hospital Districts (AWPHD) providing sample hospital policies and procedures, training videos, and webcasts for effective POLST form use in hospitals; collaboration in all these efforts with a state wide broad based community action coalition (Washington End-of-Life Consensus Coalition).
Based on these efforts and national studies3, the POLST program complements available advance directives and is extremely beneficial in confidently guiding EMS treatments in the field. Greater success of these efforts in WA and elsewhere, as described on the National POLST-Paradigm Initiative web site3, can apprise EMS professionals about the patient's treatment preferences and provide the physician's orders required to act on those wishes. This has benefit for the patient, the families of the dying, and the emergency responders. Feder, et al accurately state that these decisions are made at the EMT level. POLST provides the desired guidance for those decisions, and negates the legal and risk management concerns noted by the authors. As Oregon has demonstrated, continued perseverance in education and implementation in partnership with physicians, hospitals, nursing homes, and EMS responders, can help ensure that patients receive the treatments they want and not receive treatments they would have refused. With POLST, EMT responders can provide family support and avoid unwanted and ineffective resuscitation attempts. For Annals readers, it is important to note that a key to successful adoption of POLST is the support of a local community physician leader. Whatever the future for new guidelines like the ones studied by Feder et al, POLST and POLST-like forms and the crucial conversations among patients, families and medical providers that lead to their completion may most reliably guide emergency medical response for persons with advanced medical conditions.
Feder S, Maheny RL, Loveless RS Jr, Rea TD, Withholding resuscitation: a new approach to prehospital end-of-life decisions. Ann Intern Med. 2006;144:634-40
Kellermann A, Lynn J. Withholding resuscitation in prehospital care. Ann Intern Med 2006; 144:692-3
Meyers JL, Moore C, McGrory A, Sparr J, Ahern M. J Gerontological Nursing. 2004;30:37-46
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