Background     One barrier in the treatment of patients who are seriously ill or have advanced frailty 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. In 1991, medical ethicists in Oregon noted that treatment preferences for these patient populations were not consistently honored. Recognizing that advance directives (ADs) were inadequate for patients who frequently require emergency medical care, a tool for honoring patients’ wishes for end-of-life treatment was developed in the US. The program eventually became known as Physician Orders for Life-Sustaining Treatment (POLST). National POLST was created in 2004 to establish quality standards for POLST forms and programs, to assist states in uniform implementation, and to educate about POLST nationally. POLST has different names in different states (e.g., MOLST, MOST, POST). At the national level, it is broadly referred to as POLST. This Fast Fact will review key elements of POLST.

POLST is both a process and a portable medical order set. It is meant to be a component of advance care planning that emphasizes eliciting, documenting, and honoring patient preferences about the treatments they want to receive or decline during a health crisis or as their health status changes. This portable medical order set is designed to promote coordinated care for patients by communicating their treatment preferences as they move across care settings or travel to other states. While not solely for emergencies, POLST can communicate to emergency personnel and other health care professionals whether the patient wants to choose or decline CPR, transfer to a hospital, advanced respiratory interventions, IV antibiotics, and medically assisted nutrition. POLST aims to provide information about patient care preferences across care settings (e.g., hospitals, hospice, long-term care, and home). It can also be transferred with the patient throughout the health care system.

The Form    In 2019, National POLST introduced a National POLST form that states can choose to adopt. Almost all states have similar looking POLST forms that are divided into several sections:

• CPR decision: Resuscitate or Do Not Resuscitate (DNR).
• Treatment Orders: full treatment, selective treatments, comfort-focused treatments.
• Medically administered nutrition: providing feeding through new or existing surgically placed tubes, trial period without surgically placed tubes, none, not discussed, or no decision made.
• Signatures:  health care professional signatures are required in all states.  Patient/surrogate signature is recommended.  
• Additional orders or instructions

How It Works   The POLST decision-making process and resulting medical orders are intended for patients who are considered to be at risk for a life-threatening clinical event because of a life-limiting medical condition. This may include advanced frailty. 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 clinician (physician and/or NP/PA depending on state regulations). Many state 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. Many states have POLST registries which house the POLST form as well.

Effectiveness     Data from many completed research projects are available on the POLST website (https://polst.org/resources/citations). Key findings suggest that patients’ values are reflected in the orders, that the orders are often followed by first responders, and that treatment orders beyond CPR (e.g., medically administered nutrition) guide care that is consistent with the patient’s wishes.

State and National Initiatives     Every state in the US has a POLST form though the form and process may not yet be widely available.  Legislation is not required to implement POLST in a state, though many states have passed statutes or regulations related to POLST. National POLST can help state POLST programs create policies and materials supporting consistent implementation of POLST. All POLST Programs are invited to participate in national leadership.

Resources     National POLST’s website provides all national policies and guidance materials, the status of state programs, and other metrics related to implementation.

References

1. National POLST.  Website 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:  1^st edition published April 2007.  Revised 2^nd edition published September 2010.  Copy-edited again in July 2015. Significant revision occurred again in April 2022 led by Amy Vandenbroucke JD