POLST Programs: When Advance Directives Aren't Enough


Preparing for end-of-life care decisions is a difficult yet important task. Many people would prefer not to think about death, and some don’t know what their preferences for end-of-life care are or how to ensure they’re respected. Nevertheless, caregivers and seniors alike should be informed, realistic and proactive when trying to plan for the uncertain future.

Drafting an advance directive like a living will, completing the appropriate HIPPA authorization form, and preparing a health care proxy document (also known as a durable medical power of attorney) help to ensure that a person's unique wishes and best interests are protected later in life. But did you know that some states offer an additional program called POLST that safeguards the medical decisions of those who are seriously ill?

What is POLST?

The Physician Orders for Life-Sustaining Treatment (POLST) Program is a method of end-of-life planning specifically intended for individuals who are extremely frail, or who have life-limiting or terminal illnesses. Through a series of in-depth conversations, patients collaborate with loved ones and physicians to discuss their health issues and outline their current wishes for end-of-life care on a POLST form.

POLST forms are unique in that they are signed by a medical professional, they function explicitly as a medical order and they are meant to accompany patients as they transition through different care settings (home, hospital, nursing home, etc.). Even emergency medical personnel like EMTs and paramedics are required to abide by the POLST instructions that stipulate which life-saving treatments are to be used or avoided.

This is in contrast to advance care directives, which usually aren’t completed with the help of a health care professional and may or may not be used as guidance for emergency medical personnel. If emergency responders can't access an unconscious elder's advance directives, then their default is to provide any and all life-saving treatment. Even when a person's advance directives can be located, studies have shown that these forms are easily misinterpreted, causing patients to receive unwanted care.

The specifics of POLST programs and their respective forms vary by state, but patients can typically decide to be given comfort measures only, limited interventions that can be tailored to meet specific wishes (e.g. permitting antibiotic therapy, IV fluids and cardiac monitoring, but not intubation or mechanical ventilation) or full treatment in the event of a medical crisis.

POLST forms were also created to be easily modified to accommodate a patient’s ever-changing health and preferences. If a patient experiences a change of heart, a change in health or a change in setting, their POLST form can be voided or altered at any time as long as they retain their decision-making capabilities. (In cases where a patient is no longer competent, an appropriately appointed proxy or surrogate can consult with the treating physician to handle these decisions.)

The Benefits of POLST Programs

To help test the effectiveness of POLST forms in helping terminally ill patients receive the medical care they desire, the Journal of the American Geriatrics Society published a study of severely ill patients in Oregon, which examined the relationship between their medical stipulations on POLST forms and where they died.

The study utilized death records of 58,000 Oregonians, of which approximately 30 percent had POLST forms filed with the state's registry. Researchers then checked the association between the medical orders specified on the forms and the settings in which the individuals died.

Results showed that the overwhelming majority of patients who used POLST forms to express their desires to receive comfort measures only and avoid being hospitalized at the end of life had their wishes honored. Fewer than seven percent of individuals who specified comfort measures only on their forms died in a hospital, compared to 22.4 percent who chose limited intervention and 44.2 percent of those who requested full treatment.

Where Are POLST Programs Available?

While advance directives are easily accessible nationwide, POLST Programs are still in various stages of development around the country. As of 2020, the National POLST Paradigm Task Force has reviewed and endorsed programs in 23 states, but all 50 states and the District of Columbia have begun enacting the POLST paradigm to some degree.

Keep in mind that program names can differ by state. Variations include POST (Physician Orders for Scope of Treatment), MOST (Medical Orders for Scope of Treatment), MOLST (Medical Orders for Life-Sustaining Treatment) and TPOPP (Transportable Physician Orders for Patient Preference).

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Currently, the National POLST Paradigm only acknowledges California and West Virginia as having “mature” POLST Programs that are the standard, statewide method of end-of-life planning for those who are significantly frail or ill. If you think that a POLST form may be helpful for you or someone you care for, search the National POLST Paradigm website for information on the program in your state or region.

POLST forms address only a few medical preferences for end-of-life care, such as the administration of CPR, antibiotics, and artificial feeding and hydration. These medical orders are meant to complement (not replace) advance directives, which provide broader treatment guidelines. Every adult should have an advance directive in place, but only seriously ill, frail or terminal patients should consider completing a POLST form. If your loved one has already drafted a living will, advance directive and/or medical POA, be sure to bring copies to discuss with the physician when asking about or filling out a POLST form to ensure that these documents do not conflict.

You and your loved one must sort through delicate and complex decisions when engaging in end-of-life planning. The legal and medical paperwork may be daunting, but it is of utmost importance that the documents that are on file are accurate and up to date. These discussions can be awkward and unpleasant, but shared decision-making is what helps ensure that the patient and their care team are on the same page when it comes to their diagnosis, prognosis, values, beliefs, goals for care and treatment options.

For help with this task, discover how one veteran caregiver suggests approaching conversations with elders about end-of-life issues.

Sources: Association Between Physician Orders for Life‐Sustaining Treatment for Scope of Treatment and In‐Hospital Death in Oregon (https://onlinelibrary.wiley.com/doi/abs/10.1111/jgs.12889); POLST Paradigm Fundamentals (https://polst.org/about-the-national-polst-paradigm/what-is-polst/)

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