Please Credit Terri Schmidt, MD, MS et al, Oregon Health & Science University
POLST EMS SURVEY
Please indicate your response by placing a check before your choice or writing in your answer. Your responses will be kept confidential.
First, we would like to ask a few questions about you and your experience as an EMT:
1. What is your certification level? q EMT Basic q EMT intermediate q Paramedic
2. What is your age? q 18 –25 yrs q 26 - 34 yrs q 35 – 44 yrs q 45 – 54 yrs q 55yrs+
3. What is your gender? q female q male
4. How many years have you been an EMT at your current level?
q less than 1 year q 1-5 years q 6 – 10 years q 11-15 years q 15 years +
5. Do you work as part of a 9-1-1 system? q yes q no
6. How many hours a week do you work/volunteer in your primary EMS role? ______hours
7. Do you transport patients? q yes q no
8. Please use the attached sheet to identify your agency’s ID number. (We will use this information to assess
the average calls per day for your agency.) Primary position agency # ______.
Next, we would like to know about your personal experience with the POLST form:
9. Have you received any education about the use of POLST (Physician Orders for Life Sustaining
Treatment) form?
q yes ___formal (class or reading materials) ___informal (from peers) ___other
q no
10. To your knowledge, is the POLST form used in your community? q yes q no
11. Have you ever treated a patient with a completed POLST form?
q yes _____ patients in the last month (please estimate #)
q no (if, no skip to question 14)
12. Have you ever treated a pediatric patient (under age 18) with a filled-out POLST form? q yes q no
If yes, was the POLST helpful in making treatment decisions? q yes q no
13. Please answer the following questions based on the most recent patient you treated who had a POLST form:
a. Where was this patient located at the time you responded to the call?
q Private home q Residential Care/Assisted Living Facility q Foster home q Nursing facility q Other (please specify)______
b. Did you have any difficulty locating this patient’s POLST form? q yes q no
If yes, please describe______
______
c. Where was this patient’s POLST form located?
q front of chart q refrigerator q wallet card in wallet
q provided by family member q other , please specify ______
REMINDER: Please answer the following questions based on the most recent patient you treated who had a POLST form:
d. Was this patient’s POLST form filled out appropriately? q yes q no If no, what was wrong?
q no signature q conflicting orders q sections A or B not marked
q other, please specify ______
______
e. Did the POLST form change the treatment plan from treatments that would otherwise have been
given to this patient?
q yes q no If the plan of treatment changed, in what way(s) did it change?______
______
f. Was this patient’s POLST form over-ridden? q yes q no If yes, by whom?
q patient q family member q durable power of attorney over health care
q other, please specify ______
g. Was this case typical of situations in which the POLST form is present? q yes q no
Now we would like to know your opinions about POLST:
Please indicate whether you agree or disagree to the statements below using the following scale. Place the number that best represents your beliefs in the space provided.
1 2 3 4 5
Strongly disagree Disagree Neutral Agree Strongly agree
14. _____ The POLST form provides clear instructions about patient’s preferences.
15. _____ The POLST form is useful in determining which treatments to provide when a patient has no
pulse and is apneic.
16. _____ The POLST form is useful in determining whether or not to transport a patient to the hospital.
17. _____ The POLST form does NOT reliably express patient wishes.
18. _____ The POLST form is useful in determining what treatments to provide a patient who currently has
a pulse and is breathing.
19. _____ The POLST form is not working in my community.
20. _____ I feel more comfortable knowing what to do when a POLST form is available.
21. _____ The POLST form has made difficult decisions easier for me.
22. _____ I wish that more patients in my area had a POLST form.
23. _____ Sometimes having a POLST form makes treating patients more complicated.
(OVER)
Finally, please provide feedback about the POLST form:
24. Are there barriers to the use of the POLST form in your community? q Yes q No If yes please explain:
25. What problems, if any, have you seen with the POLST form in the field (answer only if you have had first hand experience with the POLST form in the field)?
26. In what ways, if any, has the POLST program been helpful to you in the field (answer only if you have had first hand experience with the POLST form in the field).
THANK YOU FOR YOUR TIME.
PLEASE RETURN BY JULY 17, 2002