Physician Orders for Life-Sustaining Treatment

POLST represents a significant paradigm change in advance care policy by standardizing provider communications through a plan of care in a portable way, rather than focusing solely on standardizing patients' communications via advance directives.[2]

The POLST paradigm requires providers and patients or their surrogates to accomplish three core tasks:

• First, POLST begins with a conversation between a health care professional and the patient (or the patient's authorized surrogate) about treatment options in light of the patient's current condition.[2]
• Second, the patient's preferences for treatments are incorporated into medical orders, which are recorded on a highly visible, standardized form that is kept at the front of the medical record or with the patient if the patient lives in the community.[2]

POLST forms record several treatment decisions common to seriously ill patients, for example: cardiopulmonary resuscitation; the level of medical intervention desired in the event of an emergency (comfort only, limited treatment, or full treatment); and the use of artificial nutrition and hydration. As technology and treatment options change, POLST forms will also continue to evolve.[2]

• Third, providers encourage that the POLST form travels with the individual whenever he or she moves from one setting to another, thereby promoting the continuity of care throughout a community.[2]

The POLST form is designed to transfer across treatment settings, so it is readily available to medical personal, including EMTs, emergency physicians and nursing staff.[13] The POLST program relies upon teamwork and coordinated systems to ensure preferences are honored throughout the health care system. Research suggests the POLST form accurately represents patient treatment preferences the majority of the time[14] and that the treatments provided at the end of life match the orders on the form.[15] An established POLST program can help reduce unwanted hospitalizations and honor the patient's end-of-life wishes.[1]

To determine whether a POLST form should be completed, clinicians should ask themselves, "Would I be surprised if this person died in the next year?" If the answer is that the patient's prognosis is one year or less, then a POLST form is appropriate.[16]

In a 2006 consensus report, the National Quality Form observed that "compared with other advance directive programs, POLST more accurately conveys end-of-life preferences and yields higher adherence by medical professionals." The National Quality Forum and other experts have recommended nationwide implementation of the POLST paradigm [17] Implementation of POLST was also recently recommended by the National Academy of Sciences Institute of Medicine in its report, "Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life." The report was released September 17, 2014.

Unlike advance directives, a POLST summarizes the patients' wishes in the form of medical orders.[12] An advance directive is a legal document that allows you to share your wishes with your health care team if you can’t speak for yourself. It does so by designating a person you want your medical team to work with (also known as a “surrogate”). You cannot identify a surrogate using a POLST Form. To designate a health care surrogate, patients must use an advance directive.

An advance directive allows you to generally state what treatments you would or would not want in a medical crisis, but it is not a medical order. POLST provides explicit guidance to health professionals under predictable future circumstances based on your current medical condition.[1] A POLST form turns treatment wishes outlined in an advance directive into medical orders.[18] An individual does not need to have an advance directive to have a POLST form although health care professionals recommend that all competent adults have advance directives in place. If the individual lacks decisional capacity, a surrogate can engage in the conversation and the consent process that forms the basis of the POLST process.

The challenges that patients, their families and their healthcare professionals face in a medical emergency can be daunting. Caring and sensitive communication can elicit patients' wishes that can then be documented in an advance directive. To put these preferences into actionable orders requires an additional tool, the POLST form. Healthcare professionals and their organizations can overcome the myriad barriers to communication across systems of care by developing a POLST program, creating a method that respects some of the most deeply held values of patients.[16]

• 1991: Oregon POLST Task Force Created
• 1995: First POLST form used in Oregon
• 2004: National POLST Paradigm begins
• 2006: West Virginia and Wisconsin adopt POLST. Iowa forms a focus group of health care providers to address the current fragmentation of end-of-life communication.
• 2008: POLST becomes law in California and MOLST becomes law in New York. Iowa pilot project conducted (continues until 2011).

2009: Massachusetts MOLST Demonstration Project was implemented in Massachusetts pursuant to a mandate in the Commonwealth Acts of 2008. MA MOLST form http://molst-ma.org/sites/molst-ma.org/files/MOLST%20Form%20and%20Instructions%208.10.13%20FINAL.pdf

• 2010: Illinois forms the POLST Taskforce with support from more than 60 health care organizations; the Catholic Health Association formally supports POLST.[11]
• 2011: POLST is signed into law in New Jersey [19] after Governor Chris Christie conditionally vetoes S-2197 for provisions allowing doctors to override patient wishes. Vermont requires all out-of-hospital DNR/COLST orders to be documented on the Vermont DNR/COLST form.
• 2012: First National POLST Conference held in San Diego, California.[20] Iowa passes legislation to implement the current IPOST form; Illinois passes POLST legislation (Illinois introduces a POLST form in March 2013).
• 2012: Wisconsin Catholic bishops warn against POLST[21]
• 2012: Pro-Life groups react to Wisconsin bishops' statement[22][23]
• 2012: Pro-life leaders find parallels between POLST ramifications and similar political expedients in history [24]
• 2012: The Catholic Health Association specifies how the POLST form is consistent with the Catholic Directives.[25]
• 2013: POLST becomes law in Indiana and Nevada; 20 states have POLST statutes[26]

Conservative groups like the Media Research Center and the Catholic Medical Association argue that there will be unintended consequences or potential abuses fostered by POLST adoption.[27][22][23][28] In some cases, this results from the way the enabling laws are written. Any document determining a patient's quality of care or life-ending choices carries moral and ethical dilemmas, and POLST instruments (or the protocols and circumstances through which they are explained to patients) have been criticized for this by the Catholic Medical Association. The Catholic Health Association answered criticisms in a white paper entitled “The POLST Paradigm and Form: Facts and Analysis.”

Several studies have supported the use of POLST as a tool to ensure patient wishes are complied with:

• In a 1998 study, charts of 180 residents at eight Oregon nursing facilities were evaluated over a one-year period. Where the POLST forms of residents included "do not resuscitate" and "comfort measures only" orders, none of the residents received unwanted cardiopulmonary resuscitation (CPR), intensive care, or ventilator support.[29]
• In 2004, a survey of selected sites revealed that the POLST program was widely used in Oregon nursing facilities. Care matched POLST instructions to a high degree regarding CPR (91%), antibiotics (86%), intravenous fluids (84%), and feeding tubes (94%). Level-of-care instructions (from comfort care to full medical intervention) were followed less often (46%).[30]
• A 2004 survey of 572 EMTs in Oregon found that a large majority of EMTs felt that the POLST form provides clear instructions about patient preferences and is useful when deciding which treatments to provide.[2]
• In 2009, researchers assessed the penetration of POLST in hospice programs in Oregon, Wisconsin, and West Virginia.[31] A pilot study indicated that POLST was used widely in hospices in Oregon (100%) and West Virginia (85%) but only regionally in Wisconsin (6%). A majority of hospice staff believed POLST was useful in preventing unwanted resuscitation and initiating conversations about treatment preferences.[2]
• In 2014, state death records containing cause and location of death were matched with POLST orders for people with a POLST form in the state registry. Conclusion: The association with numbers of deaths in the hospital suggests that end-of-life preferences of people who wish to avoid hospitalization as documented in POLST orders are honored.[32]
• In 2016, the study included comparison of two different state POLST programs having distinct demographics and different approaches to electronic registries. A key metric evaluated was the relationship of POLST medical intervention orders to in-hospital death, which was evaluated using POLST data linked with state death records. Conclusion: the study indicated similar patterns between the two states in which Comfort Only orders less often resulted in in-hospital deaths, compared to Full Treatment orders.[33]