Emergency Medical Services in Maryland/ Medical Orders for Life Sustaining Treatment

Transcription

1 Emergency Medical Services in Maryland/ Medical Orders for Life Sustaining Treatment Sarah Sette Assistant Attorney General for the Maryland Institute for Emergency Medical Services Systems (MIEMSS)

2 Emergency Medical Services in Maryland The overall goal of the system is to improve the outcomes of patients with acute illness or injury A guiding principle of the systems is getting the right patient, to the right hospital, in the right time, with the right care

3 Key Components of the Maryland Emergency Medical System MIEMSS state lead agency Jurisdictional EMS operational programs (volunteer and career) and commercial ambulance services Emergency departments Trauma and specialty centers Maryland State Police medevac helicopters Statewide medical communications Statewide data and quality assurance Injury and Illness prevention

4 MIEMSS Established by statute as an independent state agency with oversight by an EMS Board appointed by the Governor Responsible for effective coordination and evaluation of emergency medical services in Maryland

5 Garrett MIEMSS - Principal Roles Allegany Washington Cecil Carroll Harford Frederick Baltimore Baltimore City Kent Montgomery Anne Arundel Queen Anne s Regional Coordination Charles Prince George s Dorchester Wicomico MIEMSS supports 5 regional EMS councils Addresses inter-jurisdictional and regional issues of importance Region I Region II Region III Region IV Region V

6 MIEMSS - Principal Roles Built and maintains a statewide medical communications system Links and coordinates ambulances, hospitals, and 911 centers Dispatches helicopters Includes a 24/7 facility at MIEMSS

7 MIEMSS - Principal Roles Licensing Commercial Ambulance Services Approving Jurisdictional EMS Operational Programs Voluntary Ambulance Inspection Program

8 MIEMSS - Principal Roles Establishes standards for trauma and specialty centers, including: Stroke Cardiac Lead agency for the trauma and emergency care system Perinatal Surveys and designates centers Maintains data on trauma and specialty patients including outcomes

9 MIEMSS - Principal Roles Licenses EMS providers Over 29,000 EMS providers in Maryland Four levels of providers Emergency Medical Technician- Paramedic Cardiac Rescue Technician Emergency Medical Technician- Basic Emergency Medical Dispatcher Provider Review Panel and EMS Board manage disciplinary actions

10 MIEMSS - Principal Roles Medical Oversight And Quality Improvement Statewide EMS protocols ensure uniformity of care Statewide electronic patient care reporting Medical Directors provide oversight and medical direction

11 Maryland EMS/DNR If a patient needs transport by ambulance and is unable to communicate the desire not to be resuscitated, the patient must have an EMS/DNR Order. The EMS/DNR Order is valid only if signed by the patient s physician or nurse practitioner. Copies can be made of the EMS/DNR order and are valid.

12 Maryland EMS/DNR Order Under Current Law EMS Providers MUST Follow EMS/DNR Order EMS Providers CAN NOT Follow Advance Directive w/o EMS/DNR Order Notes in Medical Record Facility Specific DNR Order Prescription Pad Orders DNR Stickers Oral Requests From Family or Caregivers Oral Request by a Physician Who Is Not On-Site (Other Than a Medical Command (ED) Physician)

13 Maryland EMS/DNR Order Revised in August 2010 with two options: DNR Option A- Do Not Intubate: Comprehensive Care prior to Arrest then DNR DNR Option B, Supportive Care Prior to Arrest then DNR Old versions of MIEMSS DNR order forms are still honored

14 Option A Comprehensive Efforts to Prevent Respiratory/Cardiac Arrest Without Intubation DNR if arrest occurs All Treatments Under EMS Protocol Prior to Arrest EXCEPT intubation If Patient Arrests i.e. Loss of Palpable Pulse or Loss of Spontaneous Respirations - Cease Supportive Efforts

15 Option B - Limited Palliative Care Only Before Arrest, Then DNR Treat Under Palliative (Comfort) Care Protocol Prior to Arrest If Patient Arrests i.e. Loss of Palpable Pulse or Loss of Spontaneous Respirations Cease Supportive Efforts

16 Limitations of EMS/DNR Only addresses orders regarding life sustaining treatments, no other orders. No always reviewed or followed in other health care settings. An additional form that has to be filled out.

17 MOLST A standardized order form that is valid across all health care facilities and in the community MOLST = Medical Orders for Life Sustaining Treatment POLST = Physician Orders for Life Sustaining Treatment Incorporating EMS/DNR and other medical orders concerning end of life care.

18 Is there a precedent for this? POLST development began in Oregon in the early 1990 s The first POLST form was instituted in Oregon in 1995 Nine states have implemented it and thirty states are developing MOLST or POLST orders

19 The POLST and MOLST approach has resulted in much higher compliance with an individual s wishes regarding life sustaining treatments

20 What are the origins of MOLST in Maryland? 1996: First POLST work group in Maryland Multiple organizations have attempted to establish POLST 2004: Compromise -- Patient Plan of Care form 2008: Compromise with revision -- Life Sustaining Treatment Options form

21 Current Efforts State Advisory Council on End-of-Life Care formed a subcommittee to explore POLST concept in 2009 Subcommittee worked with the Attorney General s Office, Maryland Institute of Emergency Medical Services Systems, Board of Physicians, and Office of Health Care Quality Subcommittee included practicing primary care physicians and specialists in Emergency Medicine, Geriatrics, and Hospice, a nurse and lawyers Legislation to enable MOLST developed for 2011 Legislative Session

22 How does MOLST fit into Maryland s existing processes? MOLST will combine and replace the EMS/ DNR order form and Life Sustaining Treatment Options form MOLST is an order form that is valid across the continuum of care in all health care settings and in the community The CPR orders guide both EMS crews and care in other settings

23 How does MOLST fit in the process of making end-of-life choices? No form is a substitute for the discussion and process between a patient and their provider reaching decisions about lifesustaining treatments MOLST is a document that specifies orders for life-sustaining treatments

24 What are the benefits of MOLST? Consolidates important information into orders that are valid across the continuum of care It helps to standardize definitions Reminds patients and providers of available options

25 Who should complete the MOLST order form? The physician or nurse practitioner who signs the MOLST order form is responsible for the orders Before signing this or any order sheet, the practitioner must validate the accuracy of the orders Physicians and nurse practitioners should not pre-sign any blank order forms

26 What if the patient or decision maker declines to make any choices? If a choice regarding cardiopulmonary resuscitation is not made, the default order is to attempt CPR using all available treatment options If choices regarding other life-sustaining treatments are not made, then lifesustaining treatments will be offered when medically indicated

27 Is adherence to an order on MOLST mandatory in all settings? A MOLST order written in one setting remains in effect in that and subsequent settings unless the order form is voided The MOLST form shall accompany a patient when transferred to a new facility or program Receiving institutions or programs must inquire if the patient has a MOLST form

28 The Bottom Line MOLST will move Maryland significantly further in honoring an individual s wishes regarding life-sustaining treatments and end-of-life care

29 Where can I get more information? The Attorney General s website- EMS/DNR Form- t=cm9cqxoafk0%3d&tabid=68&mid=454 MOLST Proposal- st.htm