POLST, which stands for Physician Orders for Life-Sustaining Treatment, is a powerful tool for advance care planning. Known by different names in various states—such as MOLST (Medical Orders for Life-Sustaining Treatment), POST (Physician Orders for Scope of Treatment), or MOST (Medical Orders for Scope of Treatment)—POLST forms provide a clear, actionable medical order that reflects a patient’s preferences for end-of-life care. Unlike other advance directives, POLST forms are designed to be easily understood and followed by healthcare providers across different settings, ensuring continuity of care and adherence to the patient's wishes.

The POLST Process

What sets POLST apart from other advance directives is that it is both a process and a form. The creation of a POLST involves thorough discussions between the patient, their family members, and a healthcare provider—typically a physician, nurse practitioner, or physician assistant. During these discussions, the patient’s current health status, prognosis, and personal values are reviewed to establish clear medical orders for specific situations. This collaborative approach ensures that the POLST form accurately reflects the patient’s desires and is medically appropriate.

Key Components of a POLST Form

POLST forms are comprehensive, covering various aspects of medical care in a structured and detailed manner. While the specific elements may vary slightly by state, most POLST forms include the following sections:

• Patient Information: Essential details such as the patient’s name, date of birth, and identifying information.
• Cardiopulmonary Resuscitation (CPR): Clear instructions on whether or not the patient wishes to receive CPR if their heart stops beating or if they stop breathing.
• Medical Interventions: Preferences regarding the level of medical intervention, ranging from comfort measures only, which focus on palliative care, to full treatment, which includes intensive interventions like mechanical ventilation.
• Artificial Nutrition: Directives on whether the patient wants to receive artificial nutrition and hydration, such as feeding tubes or IV fluids, if they cannot eat or drink on their own.
• Documentation of Discussion: Information about the discussions between the patient, their healthcare proxy, and the healthcare provider, providing context for the orders on the POLST form.
• Signatures: The form must be signed by both the patient (or their legal representative) and the treating physician or advanced practice provider, making it a valid medical order.
• Date: The date when the form was signed, ensuring that the orders are current and relevant.

Comparing POLST with Living Wills and Health Care Proxies

While living wills and health care proxies are crucial elements of advance care planning, they serve different functions compared to POLST forms. A living will outlines a broad philosophy of care and specifies the types of medical treatments a patient prefers or wishes to avoid, particularly at the end of life. Health care proxies appoint an individual to make medical decisions on behalf of the patient when they are unable to do so, providing flexibility in decision-making based on the patient's known wishes and the specific circumstances.

In contrast, POLST forms translate these preferences into immediate, actionable medical orders that must be followed by healthcare providers. This direct applicability makes POLST forms particularly effective in ensuring that the patient’s wishes are respected in real-time, especially during emergencies or transitions between care settings. Unlike living wills, which may require interpretation and discussion among medical staff and family members, POLST forms provide clear-cut instructions that leave little room for ambiguity.

The Role of POLST in Specific Medical Conditions

While POLST is beneficial for anyone seeking to clarify their end-of-life care preferences, it is particularly impactful for individuals facing specific medical conditions.

• Advanced Cancer: For those with advanced cancer, POLST can be a guiding light. It allows patients to express their wishes regarding resuscitation, mechanical ventilation, and the transition to comfort care. This ensures that the focus shifts to pain management and quality of life when aggressive treatments are no longer desired or effective.
• Heart Failure: POLST empowers individuals with heart failure to make informed decisions about CPR, intubation, and hospitalization. By outlining their preferences in advance, patients can avoid unwanted interventions and ensure their care aligns with their values and goals.
• Dementia: As dementia progresses, decision-making capacity can diminish. POLST allows individuals to document their wishes for care while they are still able, ensuring their preferences are respected even when they can no longer communicate them. This can bring immense peace of mind to both patients and their families.
• Other Conditions: POLST is not limited to these conditions. It can be equally valuable for individuals with COPD, kidney failure, neurological disorders, or any other chronic or life-limiting illness. By proactively addressing end-of-life care preferences, POLST ensures that care remains patient-centered and aligned with individual values, regardless of the specific diagnosis.

POLST in Different Care Settings

POLST forms are not limited to a single healthcare setting. Their portability and clear directives make them invaluable across various care environments, ensuring that patient wishes are consistently honored.

• Hospitals: In the fast-paced environment of a hospital, POLST provides immediate guidance to medical teams. Whether in the emergency room, intensive care unit, or general ward, POLST ensures that interventions align with the patient's stated preferences. This is crucial in situations where a patient may be unable to communicate, allowing POLST to speak for them.
• Nursing Homes: POLST becomes an integral part of the care plan in nursing homes. It guides staff in daily care decisions, ensuring that treatments and interventions respect the resident's wishes. This fosters a sense of autonomy and dignity for residents, even as their health needs evolve.
• Assisted Living Facilities: While residents in assisted living may have greater independence, POLST remains essential. It facilitates clear communication between residents, their families, and healthcare providers, ensuring everyone is on the same page regarding care preferences. This can be particularly important during transitions to higher levels of care.
• Home Care: For individuals receiving care at home, POLST is a lifeline. It informs paramedics, home health aides, and other providers about the patient's wishes, ensuring appropriate care in case of emergencies. This can prevent unwanted hospitalizations or interventions that go against the patient's values.

Legal Considerations and State Variations

While the core purpose of POLST remains consistent across the United States, its implementation, legal recognition, and specific requirements can vary significantly from state to state.

One of the most noticeable variations is the terminology used. While POLST is the most common acronym, some states refer to these forms as MOLST (Medical Orders for Life-Sustaining Treatment), POST (Physician Orders for Scope of Treatment), or MOST (Medical Orders for Scope of Treatment). These variations can sometimes lead to confusion, but the underlying goal remains the same: to document and honor a patient's end-of-life care preferences.

Each state may also have its own unique POLST form, with slight differences in the specific questions asked, the layout of the document, and the required signatures. It's crucial for healthcare providers and patients to utilize the correct form for their state to ensure its validity and legal enforceability.

The legal status of POLST forms also varies. In some states, POLST is explicitly recognized by law as a valid medical order that must be followed by healthcare providers. In other states, POLST may not have the same level of legal authority but is still considered a valuable tool for guiding care and communicating patient preferences.

It's essential for individuals and their families to understand the legal standing of POLST in their state. This knowledge can help them advocate for their wishes and ensure that their POLST form is honored by healthcare providers across different settings.

Beyond state-specific variations, there are broader legal considerations surrounding POLST. These may include:

• Conflicts with Other Advance Directives: In some cases, there may be discrepancies between a POLST form and other advance directives, such as a living will or healthcare proxy. Legal guidance may be needed to resolve these conflicts and determine which document takes precedence.
• Capacity and Consent: The legal validity of a POLST form depends on the patient's capacity to make informed decisions about their care. If there are concerns about a patient's capacity, legal counsel may be necessary to ensure the POLST form is properly executed.
• Medical Futility: POLST forms can play a role in discussions about medical futility, where the benefits of certain treatments may be outweighed by the burdens. Legal and ethical considerations may arise in these situations, requiring careful navigation by healthcare providers and families.

Addressing Common Misconceptions Regarding POLST

There are several misconceptions surrounding POLST that can deter individuals from utilizing this valuable tool. It's important to clarify these misunderstandings:

• POLST is Only for the Elderly: This is perhaps the most common misconception. While POLST is certainly beneficial for older adults, it is not exclusive to them. Anyone 18 or older, regardless of their current health status, can benefit from having a POLST in place. It's about ensuring your wishes are known and respected, whether you're facing a chronic illness, a sudden health crisis, or simply planning for the future.
• POLST Replaces Other Advance Directives: POLST is not a replacement for other advance directives like living wills or healthcare proxies. Instead, it complements them. While living wills express your general wishes, and healthcare proxies appoint someone to make decisions on your behalf, POLST translates those wishes into specific medical orders that must be followed by healthcare providers.

POLST is Difficult to Change: Your POLST is never set in stone. It can be easily updated or revoked at any time if your wishes or medical situation changes. This flexibility ensures that your POLST always reflects your current preferences and remains a relevant guide for your care.