Administration and Leadership, Columns, Documentation & Patient Care Reporting, Patient Care

Interpretation of DNR Orders Lacks Consensus Among Prehospital Providers

Issue 6 and Volume 40.

The Research

Mirarchi FL, Cammarata C, Zerkle SW, et al. TRIAD VII: Do prehospital providers understand physician orders for life-sustaining treatment documents? J Patient Saf. 2015;11(1):9–17.

The Science

The authors conducted an electronic survey of all EMS providers in Pennsylvania in an attempt to determine how the Physician Order of Life Sustaining Treatment (POLST) document is interpreted. The survey contained six scenarios within which the patient presented with various acute conditions that deteriorated into respiratory or cardiac arrest. In each scenario the patient had POLST documentation indicating do not resuscitate (DNR) or CPR. Based on the scenario and the accompanying POLST document, those surveyed were asked to provide a code status to the patient: full code or no code. They were also asked to determine the level of patient treatment: full, limited or comfort care only. The goal of the survey was to determine the level of consensus by the respondents for each scenario. Interestingly, some scenarios were duplicated to assess reliability, and between 26–35% of the respondents changed coding responses between these scenarios.

Of the scenarios where DNR was documented with either full or limited treatment, most (59%–84%) chose no code and 25%–75% chose full code. When DNR and comfort care only was specified, almost 85% chose DNR and withheld resuscitation.

The authors concluded that POLST documents can be confusing and therefore represent a patient safety risk, recommending additional education and training be provided to EMS.

Doc Wesley Comments

This study addresses one of the most important issues in prehospital medicine. EMS providers will care for more patients with DNR orders than multiple trauma victims or anaphylaxis. Education is the key. In this study, only 30% of respondents had been provided any education on POLST interpretation and of those, half conducted their training online instead of in a didactic classroom setting. Therefore, it’s not surprising this study showed no consensus in POLST interpretation. On the other hand, a similar study in Oregon, where the POLST concept and document originated and was accompanied by robust education, demonstrated a strong consensus of POLST interpretation.

To appreciate this study’s finding, we must quickly review the contents of the POLST form. Section A has check boxes for CPR/resuscitate or DNR. Section B has check boxes for comfort care only, limited care, and full care. Sections C and D provide instructions on such things as IV fluids, antibiotics and tube feedings. Section E contains information on the patient, their healthcare representative and overall goals for healthcare.

In five of the six scenarios in this study the POLST form had DNR checked while each had different levels of care selected. This is where the confusion began. When the form states DNR and comfort care only, most EMTs are in agreement. When the form stated DNR with full or limited care, just over 50% of EMS providers in this study were able to agree the patient was not to be resuscitated.

This study highlights the shortcomings of a statewide initiative to honor end-of-life desires when it doesn’t include an appropriate level of education to EMS and other stakeholders.

I encourage anyone interested in the topic to visit to learn more about the correct manner to interpret these documents and how to implement them in your area.

Medic Wesley Comments

Medical-legal aspects of EMS are difficult topics to instruct. It becomes even more difficult in real-life scenarios where patients have immediate or urgent needs. If you add the pressure of family members and bystanders with their phones ready to record, it makes end-of-life care decisions almost impossible.

DNR forms for prehospital providers gave clarity in some states that only issued these orders for conditions that accompanied chronic and worsening conditions such as end-stage cancers. Some might argue the POLST document may be used in otherwise healthy individuals. No matter what patient population is using DNR, POLST or other personal legal documents to dictate care, the decision should never be put in the hands of the prehospital provider alone. The role of the online medical control physician must be a part of end-of-life decision-making.