POLST: What It Is and What It Is Not

A number of articles have incorrectly characterized the Physician Orders for Life-Sustaining Treatment (POLST) Paradigm Program and, as a result, reached conclusions that POLST forms should not be used.  Many of these errors simply show the authors are not familiar with the tenets or specifics of the POLST Paradigm Program, in particular, how POLST is different than advance directives and exactly who the intended population is for POLST.  This overview identifies some key areas of confusion.

The POLST Paradigm Program was developed to improve the quality of patient care and reduce medical errors by creating a system that identifies patients’ wishes regarding medical treatment and communicates and respects them by creating portable medical orders.  While the POLST Paradigm Program supports the completion of advance directives, clinical experience and research demonstrate that these advance directives are not sufficient alone to assure that those who suffer from serious, advanced, progressive chronic illnesses will have their preferences for treatment honored unless a POLST form is also completed.

A key component of the system is thoughtful, facilitated advance care planning conversations between health care professionals and patients and those close to them to determine what treatments patients do and do not want based on their personal beliefs and current state of health. In these conversations patients are informed of their treatment options and, if they wish, their health care professional completes a POLST form based on the patient’s expressed treatment references.

POLST is not for everyone; only patients with serious advanced illnesses should have a POLST form. For these patients, their current health status indicates the need for standing medical orders for emergent or future medical care. For healthy patients, an advance directive is an appropriate tool for making future end-of-life care wishes known to loved ones.  Below are some succinct statements clarifying the POLST Paradigm Program:

  1. The POLST form is a set of medical orders, similar to the do-not resuscitate (allow natural death) order.  POLST is not an advance directive.  POLST does not substitute for naming a health care agent or durable power of attorney for health care.
  2. The POLST form is for seriously ill patients for whom their physicians would not be surprised if they died in the next year, not for all patients.
  3. The POLST form is completed as a result of the process of shared decision-making. In it the patient discusses his or her values, beliefs, and goals for care, and the health care professional presents the patient’s diagnosis, prognosis, and treatment alternatives, including the benefits and burdens of life-sustaining treatment. Together they reach an  informed decision about desired treatment, based on the person’s values, beliefs and goals for care.
  4. The POLST form allows patients to have their religious values respected. For example, the POLST form allows Catholics to make decisions consistent with the United States Conference of Catholic Bishops Ethical and Religious Directives for Catholic Health Care Services, 5th ed. (2009) and ensures that those decisions will be honored in an emergency and across care transitions.
  5. The POLST form enables physicians to order treatments patients would want and to direct that treatment that patients would not want, those they consider “extraordinary” and excessively burdensome, shall not be provided.
  6. The POLST form requires that “ordinary” measures to improve the patient’s comfort and food and fluid by mouth, as tolerated, are always provided.
  7. The POLST form is actionable and prevents initiation of unwanted, disproportionately burdensome extraordinary treatment.
  8. State law authorizes certain health care professionals to sign medical orders; the POLST form is signed by those health care professionals, who are accountable for the medical orders.
  9. The POLST Paradigm Program requires health care professionals be trained to conduct shared decision-making discussions with patients and families so that POLST forms are completed properly.
  10. The POLST form may be signed by the patient or designated decision-maker (HCA, DPOA for Healthcare, or surrogate), but it is not required in all states, although the NPPTF encourages this requirement for all states seeking endorsement.  However, shared decision making is a key component of the POLST process.
  11. POLST recognizes that allowing natural death to occur is not the same as killing. POLST does not allow for active euthanasia or physician assisted suicide.