University of California San Francisco, Department of Emergency Medicine, San Francisco, USA.
Alameda County Emergency Medical Services Agency, San Leandro, USA.
BMC Emerg Med. 2022 Aug 11;22(1):145. doi: 10.1186/s12873-022-00697-3.
Physician Order for Life-Sustaining Treatment forms (POLST) exist in some format in all 50 states. The objective of this study is to determine paramedic interpretation and application of the California POLST for medical intervention and transportation decisions.
This study used a prospective, convenience sample of California Bay Area paramedics who reviewed six fictional scenarios of patients and accompanying mock POLST forms. Based on the clinical case and POLST, paramedics identified medical interventions that were appropriate (i.e. non-invasive positive pressure airway) as well as transportation decisions (i.e. non-transport to the hospital against medical advice). EMS provider confidence in their POLST interpretation was also assessed.
There were 118 paramedic participants with a mean of 13.3 years of EMS experience that completed the survey. Paramedics routinely identified the selected medical intervention on a patients POLST correctly as either comfort focused, selective or full treatment (113-118;96%-100%). For many clinical scenarios, particularly when a patient's POLST indicated comfort focused treatment, paramedics chose to use online medical oversight through base physician contact (68-73;58%-62%). In one case, a POLST indicated "transport to hospital only if comfort needs cannot be met in current location", 13 (14%) paramedics elected to transport the patient anyway and 51 (43%) chose "Non-transport, Against Medical Advice". The majority of paramedics agreed or strongly agreed that they knew how to use a POLST to decide which medical interventions to provide (106;90%) and how to transport a patient (74;67%). However, after completing the cases, similar proportions of paramedics agreed (42;36%), disagreed (43;36%) or were neutral (30;25%) when asked if they find the POLST confusing.
The POLST is a powerful tool for paramedics when caring patients with serious illness. Although paramedics are confident in their ability to use a POLST to decide appropriate medical interventions, many still find the POLST confusing particularly when making transportation decisions. Some paramedics rely on online medical oversight to provide guidance in challenging situations. Authors recommend further research of EMS POLST utilization and goal concordant care, dedicated paramedic POLST education, specific EMS hospice and palliative care protocols and better nomenclature for non-transport in order to improve care for patients with serious illness.
在所有 50 个州都存在某种形式的医生维持生命治疗订单（POLST）。本研究的目的是确定护理人员对加利福尼亚州 POLST 进行医疗干预和运输决策的解释和应用。
本研究采用了加利福尼亚湾区护理人员的前瞻性便利样本，他们对六名患者的虚构场景和伴随的模拟 POLST 表格进行了回顾。根据临床病例和 POLST，护理人员确定了适当的医疗干预措施（即无创正压气道）以及运输决策（即根据医疗建议不将患者转运至医院）。还评估了护理人员对 POLST 解释的信心。
有 118 名护理人员参加了调查，平均有 13.3 年的急救经验。护理人员通常会正确识别患者 POLST 上选定的医疗干预措施，这些干预措施是舒适为重点的、选择性的还是全面的治疗（113-118；96%-100%）。对于许多临床情况，特别是当患者的 POLST 表明舒适为重点的治疗时，护理人员选择通过基地医生联系进行在线医疗监督（68-73；58%-62%）。在一种情况下，POLST 表明“仅在当前地点无法满足舒适需求时才将患者转运至医院”，13（14%）名护理人员选择无论如何都转运患者，而 51（43%）名护理人员选择“非转运，违反医疗建议”。大多数护理人员同意或强烈同意他们知道如何使用 POLST 来决定提供哪些医疗干预措施（106；90%）以及如何转运患者（74；67%）。然而，在完成案例后，当被问及他们是否认为 POLST 令人困惑时，类似比例的护理人员表示同意（42；36%）、不同意（43；36%）或中立（30；25%）。
POLST 是护理人员照顾患有严重疾病的患者的有力工具。尽管护理人员对自己使用 POLST 来决定适当的医疗干预措施的能力充满信心，但许多人仍然发现 POLST 令人困惑，特别是在做出运输决策时。一些护理人员依靠在线医疗监督来提供指导，以处理具有挑战性的情况。作者建议进一步研究 EMS POLST 的使用情况和目标一致的护理，专门的护理人员 POLST 教育，特定的 EMS 临终关怀和姑息治疗方案以及非转运的更好命名，以改善患有严重疾病的患者的护理。
