The POLST Paradigm is a clinical process designed to facilitate communication between health care professionals and patients with serious advanced illness or frailty (or their authorized surrogate) where the health care professional would not be surprised if the patient died within the next year. The process encourages shared, informed medical decision-making leading to a set of portable medical orders that respects the patient’s goals for care in regard to the use of cardiopulmonary resuscitation (CPR) and other medical interventions, is applicable across health care settings, and can be reviewed and revised as needed.
In 1991 leading medical ethicists in Oregon discovered that patient preferences for end-of-life care were not consistently honored. Recognizing that advance directives were inadequate for the patients with serious illness or frailty — who frequently require emergency medical care — a group of stakeholders developed a new tool for honoring patients’ wishes for end-of-life treatment. After several years of evaluation, the program became known as Physician Orders for Life-Sustaining Treatment (POLST).
In September 2004 the National POLST Advisory Panel, later known as the National POLST Paradigm Task Force (NPPTF), convened to establish quality standards for POLST Paradigm Forms and Programs and to assist states in developing the POLST Paradigm.
The POLST Paradigm is neither a federal mandate nor program but is developed at the state level, either through grassroots efforts or legislation. The POLST Paradigm fundamentals are the same but there may be differences among the states. The National POLST Paradigm Task Force creates quality standards for states to follow, helping to ensure patients can have their POLST Form honored throughout the United States.
You can learn more about a state’s POLST Program by clicking on the state here: http://www.polst.org/programs-in-your-state/
The POLST Form documents the medical order that helps give patients more control over receiving treatments they do want to receive—and avoiding treatments they do not want to receive—in the event they cannot speak for themselves during a medical crisis. All competent adults should have advance directives, documenting who they want to speak for them whenever they lack capacity to speak for themselves. The POLST Form is different but complements an advance directive.
A better question might be “Does POLST identify DNR preferences?” Yes — but it does more! A POLST provides additional information that helps emergency personnel determine what treatments they should provide to a patient. Rather than automatically going to the hospital, a POLST may help keep the patient comfortable where they are located, if that is the treatment level they have chosen.
Like a DNR, a POLST Form lets EMS know whether or not the patient wants CPR. DNR orders only apply when a person does not have a pulse, is not breathing and is unresponsive. However, in most medical emergencies, a person does have a pulse, is breathing or is responsive. That’s where POLST is different.
A POLST Form provides more information to emergency personnel than a DNR by indicating that:
- The patient still wants full treatment, meaning that they want to go to the hospital and that all treatment options should be considered, including use of a breathing machine;
- The patient wants limited interventions, meaning that they want basic medical treatments but wish to avoid the intensive care unit (ICU); or
- The patient just wants comfort measures meaning that they do not wish to go to the hospital but want to be made comfortable wherever they are living.
This additional section about desired medical treatments that a POLST Form provides is incredibly important. Research has shown that, when someone completes a DNR, health care professionals assume the patient wants less treatment. Research looking at POLST Forms in Oregon shows that that is not the case: approximately half of patients who complete a POLST Form in Oregon indicating that they do not want CPR also show that they want full treatment or limited interventions (or a higher treatment level).
The POLST Paradigm Form is not for everyone; a POLST Paradigm Form is 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.
No. Completion of a POLST Paradigm Forms should never be mandatory. Just as patients are not required to complete an advance directive or a DNR order, they should not be required to complete a POLST Paradigm Form.
Facilities may have policies requiring certain patients be offered the opportunity to have the conversation and complete one, but completion of a POLST Paradigm Form should always be voluntary.
The POLST Paradigm Form is a medical order and must be signed by a physician, nurse practitioner or physician assistant to be valid (depends on state law). Each form has a statement or attestation that the health care professional's signature on the form indicates the orders on the form reflect the patient's treatment wishes.
Most states also require the patient or their surrogate to sign the form (and even in states where the patient’s signature is not required, we encourage the patient to sign indicating their agreement to the orders). Patients should never be given a POLST Paradigm Form and asked to fill it out.
A health care professional, a patient with capacity, or the patient's surrogate if the patient lacks capacity can void the form at any time. A line should be drawn through all sections of the form and the word “VOID” should be written in large letters if the POLST Form is updated or if the patient (or his/her surrogate) wishes to no longer use a POLST Paradigm Form. Patients should be encouraged to let their health care professionals know if they have voided their form.
Some states have registries for POLST Paradigm Forms and, in those states, the health care professional must let the registry know the form has been voided.
As a clinical matter, a patient's POLST Paradigm Form should be reviewed periodically and updated if:
- The patient is transferred from one care setting or care level to another (including upon admission or at discharge);
- There is a substantial change in the patient’s health status; or
- The patient's goals of care and/or treatment preferences change.
Review of the patient’s POLST Paradigm Form upon discharge or transfer for one care setting to another, is critical. When a patient is leaving a care setting, health care professionals should review the form with the patient to:
- confirm the orders are still accurate,
- update the form to reflect new preferences, or
- void the form if the patient is not within the appropriate POLST population.
No. Only an advance directive may be used to appoint a surrogate. However, most POLST Paradigm Forms ask for this information on the second side of the form and this information should also be reviewed and updated whenever the form is reviewed with the patient.
The valid version of POLST Paradigm Forms are in English; however, to assist limited or non-English speakers states may create translations of these forms to assist with the conversation. These non-English forms are intended to be used to help patients, caregivers and loved ones understand the POLST Paradigm Form but they are not intended to be used as the final form and, therefore, should not be signed.
Parallel to the general rule for advance directives, health care professionals should be able to presume the validity of a POLST Paradigm Form. A health care professional who honors a POLST Paradigm Form should not be subject to any sanctions, as a result of his or her reliance on the form, so long as the health care professional believes “in good faith” both that the form is valid and that it has not been revoked. In this regard, reliance on a POLST Paradigm Form is equivalent to reliance on any other medical order.
No. An advance directive is a legal document that allows the patient to share his/her wishes with his/her health care team if he/she can’t speak for his or herself. While the form varies in name and information by state, generally an advance directive allows a patient to:
- Identify the person he/she wants the health care team to work with in making decisions about his/her medical care (known as a “surrogate”). A POLST Form cannot be used to identify a surrogate.
- Generally say what kinds of medical treatment he/she would or would not want and is not specific to a particular medical condition (such as advanced heart disease, advanced lung disease or cancer). An advance directive is a legal document that should be completed by all adults.
The POLST Form complements an advance directive; it does not replace it.