Nebraska Emergency Treatment Orders (NETO)

Why NETO?

Emergencies Happen

Everyday, Nebraskans  experience  medical emergencies and serious accidents that leave them unable to speak for themselves. Without the patient's voice, decisions are made to start or stop treatment that may conflict with thier wishes or force family members to bear the responsibility for painful choice.

Decisions are Required

Emergencies require rapid action, yet most people are too sick or injured to make their own decisions so the medical system assumes that all people want every treatment treatment available. This is true for some people, but other want to place reasonable limits on either the type or duration of treatment they accept. 

Speak for Yourself!

You can control the treatment you accept as long as medical professionals have to have a reliable way to know what you want. NETO lets you make important treatment decisions for yourself so that you get the treatment you want. 

The information you need

Medical Professionals

Licensed Medical Providers can get information here about how to use NETO in your practice or facility

Community Organizers

People who want to use NETO in your community can get information here about building a system of care

Patients and Families

Individuals and families can get information about using NETO to  consider emergency decisions and  document your choices

NETO Basics

What exactly is a NETO?

A NETO converys your treatment choices if you are unable to make decisions for yourself. It is a bright yellow piece of paper that contains your witnessed declaration to accept, limit, or refuse medical treatment on one side and an attestation and medical orders for EMS or other first responders on the other side. The declaration is in the form of four standardized questions that match the needs of a patient as they experience a medical emergency that leaves them unable to make or communicate thier own decisions. 

What are the questions?

  1. Scope of treatment. Before knowing exactly what might have happened to you, do you want to place any limits on your treatment? While many people want everything medicine can offer, a growing number of aged or seriously ill people want to place limits on the treatment they receive. There are three general level of treatment that can help guide your treatment to match your goals and values. 
  2. Indications for stopping treatment. Even the best treatment deosn't always provide the outcomes we want. If the treatment that was started doesn't work as well as hoped, some people would want to continue trying as long as there is any chance of staying alive, even if it meant being on long-term life support or living with pain and debility. Others would want to stop and the most common reasons for stoping treatment are offered as options.
  3. Resuscitation status for cardiac arrest. Do you want to try to bring you back if you die from cardiac arrest? You should talk to your doctor about the advisability of CPR given your particular health status and values. We find that people vastly over estimate the success of CPR and are surprised when they learn that about 50% of people die during CPR, 25% die later in the hospital, 15 % have clinically significant neurologic damage and about 10% go on to survive with good outcomes.  
  4. Medically administered nutrition and hydration. If, after acute medical treatment, you were still unable to make your own medical decisions AND you were unable to take food and drink by mouth, would you want to be kept alive by putting nutrients directly in your stomach through a tube? 

What is the Attestation?

This form was designed to be created by a person in collaboration with a physician, nurse practitioner or physcians assistant. This helps assure that people understand their choices in the context of thier personal health status. The physician attests that they have talked to the patient about thier choices, that they seem to understand them and that they had the ability to make medical decisions at the time it was signed. 

Why do I need Orders?

When you call 911 emergency responders rush out with orders to  administer medical life sustaining treatments if they are required. They assume that if you called 911 you want everything they can do. If you DON'T want CPR, Intubation or to be transported to the hospital the EMS providers need orders from another physician to suspend thier protocols. This section clearly states if you DO or DO NOT want each of these three options and provides EMS with the orders they need.


Why is this better than a Living Will or Power of Attorney?

  1. Living Wills just don't work in real practice. They are rarely written with a person's specific health in mind. They are written in legal language that doesn't translate into medicate treatment very clearly. They were written to avoid futile treatment, but leave little room to refuse treatment that is simply unwanted. And, they are highly variable so that medical professionals can't find the answers they need in in time to treat an emergency. 
  2. With little guidance from the living will, a patent's power of attorney or next of kin is left answering medical questions at a time when they are emotionally overwhelmed. While a few people have had very specific conversations with their family about their choices, most have not. This leaves loved ones to make painful choices and feeling responsible for things that are often beyond their control. Having a NETO allows you to speak for yourself about the major issues and let's your family fill in the detail, a much more manageable task.  

What if I change my mind?

NETO was designed to be revised with a simple visit to your doctor. While many decisions will last for years, changes in health or family status can lead to changes in your choices. The most recently signed and dated NETO prevails. 

Community Organizers

NETO is the foundation for a system of care that respects patient choices

Good decisions lead to appropriate care, but those decision have to be communicated across a whole community to make sure we respect patient choices. This section details some of the ground work required to assure your community is ready to start using NETO. 

Leadership

It is best to collect a group of engage community members from across the spectrum of care. Consider including representatives from the hospital, EMS, physicians, nursing facilities, churches  and organizations who advocate for the elderly or specific illness populations. Work toward building consensus about the need to improve continuity of care and adherence to patient wished for emergency treatment. Think about a communication plan to reach out to the rest of the community. Set targets to mark your progress. How many doctors have signed on to participate? How many facilities? What percnetage of the population have a NETO? These are all metrics you could follow to guage teh success of your program .

The Minimum System

In order for the NETO to be effective you need three key pieces in place:

  1. Emergency Medical Services and medical transport. The NETO is consistent with the Nebraska EMS protocols, so the providers in your area just need to be made aware of  the forms and how to respond when they encounter them. Most seasoned staff are greateful to have clear consistant direction. You can use the accompanying  video and power point to get things started. 
  2. Emergency department staff.  The people in the emergency department need to be in strong support of the program. Many ED providers are happy to have clear instructions about treatment choices, but some have concerns. NETO was create to ally the concerns of emergency providers.
  3. Physician champions. You'll need at least a small group of physicians who understand the value in helping patients plan for emergencies and who are comfortable with those conversations. Marketing and educational materials are available for offices. 

With at least these three elements in place you are ready to start a small scale trial.


Hospitals and Facilities

Hospitals and facilites will need to know how to handle the new forms. Though the NETO is new, it fits the description of and Advanced DIrective, so should be handled in the same manner.  The Patient Self Determination Act of 1991 requires that all healthcare facilities accept and honor a patients directives. Even so, they will need to plan for how it will be handled in thier systems. They may want to look at thier "code status" policies to make sure that the signed NETO will be honored at the time of admission. Since the NETO is designed to improve continuity, it may be initiated in the hospital prior to discharge, or an existing form may be revised in the hospital after a patient receives more information about thier illness. Appropriate policies and procedures may need to be developed. 

Getting material

The NETO forms and educational materials have been developed free of charge to users who are welcome to print them in thier community. Started packs of material are available through:_____ To preserve uniformity and standardization, no alteration may be made to the form. Any suggestions for improvement should be made to the founding committee.

Pilot Information

The NETO is currently being piloted in Omaha and the surrounding communities. If you'd like more information, please feel free to contact us.