EMS Instructions for Nevada POLST form #090817.
Nevada’s POLST program has made patient treatment clearer
Whether responding to a patient in a health care facility or at their home, the first question from EMS should be whether the patient has a POLST form and, if at home, EMS should look on the refrigerator or next to the bed (patients are instructed to place their POLST form in either of these two locations). If the patient has a POLST form, the first thing to check is if Section E is signed and dated by a provider (Physician, APRN or PA) and by the patient, their DPOA, legal guardian, parent (if a minor) or surrogate. If so, it is a valid, legal POLST order and should be honored.
Next, check Section A if the patient is in arrest, otherwise, consult Section B which will direct what specific treatment the patient wants. Unlike other Advance Directives, the directives of a POLST are medical orders that are intended to be honored by any provider of health care who treats the patient in any health-care setting, including, without limitation, the patient’s residence, a health care facility or the scene of a medical emergency (Nevada Statute). Therefore, the state issued salmon colored DNR identification is still valid, but is no longer required, the POLST form is a newer DNR order designation.
In addition, regardless of authority, a provider of health care shall comply with a valid POLST form, regardless of whether the provider of health care is employed by a health care facility or other entity affiliated with the physician, Advance Practice Registered Nurse or Physician Assistant who executed the POLST form (Nevada Statute). Therefore, the medical director of a Nevada EMS shall comply with a valid POLST regardless of whether that medical director signed and dated the POLST and shall furthermore direct EMS responders to honor the medical orders in Sections A and B of the POLST form.
In other words, Nevada law states that EMS shall honor the medical orders established in Sections A and B of a POLST regardless of setting, unless the POLST is not signed and dated (required for validation) by a physician, APRN or PA in Section E and the patient, their representative or surrogate decision-maker.
What does EMS do with a POLST?
- 1. Do not ask others present whether they want you to follow the POLST; if questioned, explain that the POLST is a medical order that reflects the patient’s wishes and your duty is to follow the orders.
- 2. Verify it is valid (has it been signed and dated in Sections C and F).
- 3. Unless you have reason to believe there is another AD that conflicts and is more recent than the POLST, provide treatment that complies with POLST. By law your medical director is directed to comply with the POLST regardless of the affiliation or authority of the physician who signed the POLST form. Therefore, you should follow the medical orders in Sections A and B. Perform CPR only as appropriate and if indicated in Section A, otherwise make the patient and their loved ones as comfortable as possible.
- 4. Should you transport the patient, take the POLST with you. Should the patient experience cardiopulmonary arrest en route, follow the directives in Section A.
- 5. The POLST shall be provided to the receiving facility with the patient.
What do I do with information in Section B
- If “Comfort Focused Treatment” is checked, then the patient should stay where they are, not be transferred and all measures should be taken to make them comfortable unless comfort cannot be achieved at the current location. Assure the family or loved ones that this is what the patient wanted and if there are processes that may be disturbing to the family, explain what is being done and why. If comfort cannot be achieved at the patient’s location, they may be transferred to a facility that can manage their comfort. In this case, be sure to TAKE THE POLST FORM with you.
- If “Selective Treatment” is checked, avoid intubation, advanced airway interventions or mechanical ventilation. Non-invasive positive airway pressure may be used. Hospital transfer as indicated.
- If “Full Treatment” is checked, proceed as appropriate.
What do I do with information in Section C
In Section C. check to see if the box “No IV fluids” is marked and avoid these measures if they are checked.
What if someone at the scene objects to the POLST orders?
Only the patient, their legal representative (the Durable Power of Attorney for Health Care (DPOA) / Agent as established on an Advance Directive, the parent of a minor or a legal guardian) or surrogate (only a surrogate who has signed the POLST) may over-ride the POLST orders. If someone presents an Advance Directive naming them as the patient’s Agent/DPOA, or they are the parent of a minor or the patient’s legal guardian or they are the same surrogate who signed the POLST, then they may over-ride the POLST orders.
HOWEVER, what has proven effective when ANYONE objects, is to explain that the POLST was completed with the patient while they had decisional capacity, they discussed the choices with their health care provider and decided what treatment they wanted at this time. Explain that this may have been one of the very last decisions the patient was able to make, and ask if the person who is objecting is comfortable over-riding this last wish.
What happens if a patient’s POLST conflicts with a state issued Do-Not-Resuscitate identification?
The most recent and valid document should be honored.
What constitutes a valid POLST?
Nevada law establishes that a valid POLST must be signed and dated by a physician, APRN or PA in Section F and the patient, their representative or surrogate. If a POLST is not both signed and dated in both of these sections, then it is not valid and treatment should be determined by best practices.
May I be prosecuted if there is another AD that I don’t know about?
NRS 449.6952 establishes that a provider of health care may assume the validity of a POLST form unless he or she has knowledge to the contrary and cannot be prosecuted if they have no knowledge of a POLST form.
A provider of health care is not guilty of unprofessional conduct or subject to civil or criminal liability if that treatment complies with a valid POLST form, provider of health care is unaware of the existence of the POLST form or in good faith believes that the POLST form has been revoked, or the patient, their agent as established in a Durable Power of Attorney for Health Care (DPOA), parent of a minor or legal guardian of the patient revokes the POLST (NRS 449.6948).
Does death resulting from compliance with the POLST constitute suicide or homicide?
Death that results when emergency care or life-sustaining treatment has been withheld pursuant to a POLST does not constitute a suicide or homicide (NRS 449.6954).
What if a patient is pregnant?
Life-sustaining treatment must not be withheld or withdrawn regardless of the medical orders of a POLST form if the patient is known to the attending physician, APRN or PA to be pregnant, so long as it is probable that the fetus will develop to the point of live birth with the continued application of life-sustaining treatment (NRS 449.695.4).
What if a patient’s POLST is from another state?
There are many states with programs similar to Nevada’s POLST. Some have other titles: POST, MOST, MOST, COLST, etc., but all share the feature of establishing patient’s wishes as medical orders to be honored across health care settings. Nevada law provides for EMS to honor an out of state POLST program form (NRS 449.696).
See POLST NRS 449.691-697 for more detail regarding Nevada law and the Nevada POLST program.