POLST (Physician Orders for Life-Sustaining Treatment) is an approach to improving end-of-life care in the United States, encouraging providers to speak with the severely ill and create specific medical orders to be honored by health care workers during a medical crisis. POLST began in Oregon in 1991 and currently exists in 46 states; some of the 46 states have the program in development. The POLST document is a standardized, portable, brightly colored single page medical order that documents a conversation between a provider and an individual with a serious illness or frailty towards the end of life. A POLST form allows emergency medical services to provide treatment that the individual prefers before possibly transporting to an emergency facility.
The POLST form is a medical order which means that the POLST form is always signed by a medical professional and, depending upon the state, the person stated on the form can sign as well. A pragmatic rule for initiating a POLST can be if the clinician would not be surprised if the individual were to die within one year. One difference between a POLST form and an advance directive is that the POLST form is designed to be actionable throughout an entire community. It is immediately recognizable and can be used by doctors and first responders (including paramedics, fire departments, police, emergency rooms, hospitals and nursing homes). Comparing to documents like DNI (Do Not Intubate), DNR (Do Not Resuscitate) and advance directive, the POLST form provides more information on the types of end-of-life treatment or intervention that the severely ill wishes to receive.
Organizations that have passed formal resolutions in support of POLST include the American Bar Association and the Society for Post-Acute and Long-Term Care Medicine (AMDA). Other organizations that support POLST include the American Nurses Association (ANA); the Institute of Medicine; National Association of Social Workers (NASW); AARP; the American Academy of Hospice and Palliative Medicine (AAHPM); Pew Charitable Trusts; and the Catholic Health Association of the United States (CHA).
POLST orders are also known by other names in some states: Medical Orders for Life-Sustaining Treatment (MOLST), Medical Orders on Scope of Treatment (MOST), Physician's Orders on Scope of Treatment (POST) or Transportable Physician Orders for Patient Preferences (TPOPP).
What is POLST?
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 individuals' communications via advance directives.
The POLST paradigm requires people, their surrogates, and their providers to
accomplish three core tasks:
First, POLST begins with a conversation between a health care professional and the individual (or the individual's authorized surrogate) about treatment options in light of the individual's current condition. Second, the individual'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 individual if they lives in the community.
POLST forms record several treatment decisions common to seriously ill individuals, 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.
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.
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. 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 individual's treatment preferences the majority of the time and that the treatments provided at the end of life match the orders on the form. An established POLST program can help reduce unwanted hospitalizations and honor the person's end-of-life wishes.
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.