Background     One barrier in the treatment of seriously-ill and dying patients has been the inability to develop a system by which a patient’s preferences for life-sustaining treatment are both documented and honored across different care sites. Regional and statewide programs have tackled this problem with variable success. Originally started in Oregon in 1991, the Physician Orders for Life Sustaining Treatment (POLST) Program creates a coordinated system for eliciting, documenting, and communicating the life-sustaining treatment wishes of seriously-ill patients.  Programs with the essential core elements of POLST are developing in the majority of states.  Although different states may use different names, the program is universally referred to as the POLST Paradigm Program. This Fast Fact will review key elements of the POLST Paradigm Program.

The Paradigm   The POLST Paradigm was developed as a standardized, advance care planning document to be completed by health care professionals, together with a patient or surrogate decision-maker.  The POLST form translates the values expressed in an advance directive into immediately active medical orders which do not require interpretation or further activation. POLST aims to provide continuity of care for patients according to their preferences across all care settings (e.g. hospitals, hospice, long-term care and home), and is transferred with the patient throughout the health care system. In each region or state, local leaders have presented widespread education to support its application across the spectrum of health care settings.

The Form    The form is brightly colored to facilitate identification and is divided into several sections:

• CPR decision: Resuscitate or Do Not Resuscitate (DNR).
• Scope of treatment: comfort measures vs. limited additional interventions vs. full treatment.
• Medically administered nutrition: none vs. defined trial period vs long-term use.
• Health care professional signature:  in some states or regions, patient/surrogate signature is strongly recommended or required.

How It Works    POLST is designed for seriously-ill adults or those who are medically frail. Completion of the form is voluntary. The health care professional turns the patient’s values (expressed personally through conversation, and/or an advance directive, or by the patient’s legal representative if the patient lacks decision-making capacity) into actionable medical orders. The orders are valid when signed by a physician (or NP/PA depending on state regulations). Many state/regional POLST programs also require the patient’s or legal agent’s signature to make the form valid.  A copy of the POLST form is included in the medical record while the original remains with the patient as they move across care settings.

Effectiveness     Data from completed research projects related to POLST are available on the POLST website (www.polst.org). Key findings indicate that patients’ values are accurately reflected in the orders, that the orders are followed by first responders, that life-sustaining treatment orders beyond CPR (e.g. artificial nutrition) are useful to guide care consistent with the patient’s wishes, and that implementation can evolve to become a standard of care in a community, region, or state.

State/Regional Initiatives     Numerous communities and states are developing or have implemented programs similar to Oregon’s with the guidance of the National POLST Paradigm Task Force.  The names of endorsed programs include: Medical Orders for Life Sustaining Treatment or MOLST (New York); Medical Orders for Scope of Treatment or MOST (North Carolina); POLST (California, Hawaii, Oregon, Wisconsin, Washington state); and Physician Orders for Scope of Treatment or POST (West Virginia, Tennessee).

Resources     The POLST website has sample downloadable forms, educational materials and videos; a map of states and regions using the form, contact information; a description of the core elements of a POLST Paradigm Program; and information on how to  build a coalition to start a POLST Paradigm Program available at no cost. There may be a low cost for larger orders to help cover expenses of a state or regional program’s coordinating center. The Center for Ethics in Health Care at Oregon Health & Science University coordinates the national initiative.

References

1. Physician Orders for Life-Sustaining Treatment Paradigm.  Available at:  http://www.polst.org. 
2. Tolle SW, Tilden VP, Dunn P, Nelson C.  A prospective study of the efficacy of the physician orders for life sustaining treatment. J Amer Ger Soc. 1998; 46:1097-1102.
3. Hickman SE, Hammes BJ, Moss AH, & Tolle SW. Hope for the future: achieving the original intent of advance directives. The Hastings Center Report Special Report. 2005; 35(6—Suppl):S26-S30.
4. Hickman SE, Nelson CA, Perrin NA, Moss AH, Hammes BJ, Tolle SW.  A comparison of methods to communicate treatment preferences in nursing facilities: traditional practices versus the physician orders for life-sustaining treatment program.   J Amer Ger Soc.  2010; 58:1241-1248.

Author Affiliations:  Coalition for Compassionate Care, Sacramento CA (JC); West Virginia University, Morgantown, WV (AHM); Oregon Health & Science University, Portland, OR (MC, ST).

Version History:  1st edition published April 2007.  Revised 2nd edition published September 2010.  Copy-edited again in July 2015.