The POLST Paradigm was developed to improve the quality of patient care 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 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 illnesses or frailty will have their preferences for treatment honored unless a POLST Form is also completed.
Research shows that by recording people’s wishes based on their present condition and updating those orders as the condition or wishes change, a POLST Form is not only effective in capturing individual preferences, but does so more accurately than traditional advance directives for individuals with serious illness or frailty. Individuals with POLST Paradigm orders reflecting a preference for comfort measures were also less likely to receive life-sustaining medical intervention than individuals with POLST full-treatment orders – reflecting the fact that POLST Paradigm orders result in greater adherence by medical personnel.
A survey of hospices in three states found that POLST Paradigm Forms were useful in preventing unwanted medical care and at initiating conversations about treatment preferences. The survey also found that health care professionals respected treatment limitations specified in POLST Paradigm Forms 98% of the time and that no patients received unwanted CPR. A prospective study of nursing home residents with POLST Paradigm orders for DNR and Comfort Measures Only found that none received unwanted CPR, ICU care, or ventilator support.
A POLST Paradigm Form can also help ensure people receive desired treatment. For example, a 2014 study of forms in the Oregon POLST registry found that 33.1% of forms contained orders for limited or full treatment. The earlier three-state survey of hospices found that 78% of patients specified something more than comfort measures.
Short Form (66 words):
The National POLST Paradigm improves the quality of care for patients who are seriously ill or frail by creating a voluntary system that elicits, documents and honors patient medical treatment wishes through portable medical orders. A Physician Orders for Life-Sustaining Treatment Paradigm Form is completed based on conversations between patients and health care professionals about goals of care, quality of life, diagnosis, prognosis and treatment options.
Long Form (192 words):
The National POLST Paradigm improves the quality of care for patients who are seriously ill or frail by creating a system that elicits, documents and honors patient medical treatment wishes through portable medical orders. The POLST Paradigm is part of advance care planning, a process that includes conversations between patients and health care professionals about goals of care and quality of life. Everyone is encouraged to complete an advance directive but recognize its limitation: advance directives are not medical orders so emergency personnel cannot follow guidance provided in an advance directive during a medical emergency. Instead, once the patient is in the hospital and stabilized, the health care team works with the surrogate identified in the advance directive and reviews the patient’s wishes to develop a treatment plan. With a POLST Paradigm Form, the treatment plan is developed in advance and moved upstream; the medical orders on the form give clear instructions to emergency personnel about whether the patient wanted CPR and whether they wanted to go to the hospital or remain where they are. The POLST Paradigm is always voluntary and should be available to all seriously ill or frail individuals.
- A POLST Paradigm Form is not an advance directive, but it is an advance care planning tool. An advance directive is a mechanism for naming a health care agent or durable power of attorney for health care and providing general treatment wishes. A POLST Paradigm Form is a portable, actionable medical order that helps ensure patient treatment wishes are known and honored and helps prevent initiation of unwanted, disproportionately burdensome extraordinary treatment.
- The POLST Paradigm is voluntary — it should never be mandatory to complete a POLST Paradigm Form.
- It is imperative to the POLST Paradigm that the process of completing a POLST Paradigm Form involve informed, shared decision-making between patients and health care professionals. The conversation involves the patient discussing his/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 patient’s values, beliefs and goals for care.
- The POLST Paradigm is not for everyone; POLST Paradigm Forms are appropriate for patients with serious illnesses or frailty for whom their health care professionals would not be surprised if they died within a year. 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.
- A POLST Paradigm Form allows patients to have their religious values respected. For example, the POLST Paradigm 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.
- A POLST Paradigm Form enables health care professionals to order treatments patients would want during a medical crisis, helping avoid the provision of treatments patients would not want, such as those that the patient considers “extraordinary” and excessively burdensome.
- A POLST Paradigm Form requires that “ordinary” measures to improve the patient’s comfort, and food and fluid by mouth as tolerated, always be provided.
- 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.
- A POLST Paradigm requires health care professionals be trained to conduct informed shared decision-making discussions with patients and families so that POLST Paradigm Forms are completed properly.
- A POLST Paradigm Form may be signed by the patient or designated decision-maker (HCA, DPOA for Healthcare, or surrogate), but this is not required in all states. The National POLST Paradigm Task Force encourages patient or surrogate signatures (or witnessed verbal consent) be required on POLST Paradigm Forms.
- The POLST Paradigm is not about how you want to die, it is about how you want to live with the time you have left.
- The National POLST Paradigm recognizes that allowing natural death to occur is not the same as killing. See DWD - POLST Statement
The POLST Paradigm Form is not for everyone; POLST Paradigm Forms are appropriate for patients with serious illnesses or frailty for whom their health care professionals would not be surprised if they died within a year. For these patients, their current health status indicates the need for standing medical orders for emergent or future medical care. Also, these are the patients at the greatest risk of having a medical emergency but who may not want our standard of care (standard of care currently being that everything possible to attempt to save someone's life must be done).
For healthy patients, an advance directive is an appropriate tool for making future end-of-life care wishes known to loved ones.