POLST is an acronym for Physician Orders for Life Sustaining Treatment. More than 50 percent of US states have POLST or are in the process of developing a form of it. This is part of a national movement to establish a standardized medical form to document wishes for people with serious illness. In some states, the form is called MOLST (Medical Orders for Life Sustaining Treatment), and there are a few other variations on that wording.
Oregon started the POLST movement in 1991, and the order is now integrated throughout the state's healthcare system. Since it is a physician's order, it can be accessed and followed whether the person is in a hospital, at home, in a skilled nursing facility, or in assisted living.
This system is providing a way to improve communications about end-of-life wishes when patients cannot speak for themselves. The form addresses code status, medical interventions at the end of life (IV fluids, antibiotics, artificial nutrition, etc.), and the wish to return to the hospital. The patient and doctor have a conversation about those wishes and sign the order form, which is then followed in every site of care.
Here is an example of how it is used.
Mr. A, an 88-year-old patient, has just transferred to a nursing home from the hospital. He is very frail and has a long history of end stage heart failure. He completed a POLST form with his doctor in the hospital. Mr. A told his doctor that he did not want to return to the hospital. He wants no aggressive measures taken if his heart should stop, and he does not want a feeding tube. The document came with him to the nursing home. When he is found unresponsive that night, the nursing home staff has the POLST form and knows that he does not want to return to the hospital. So he is kept comfortable right there. His family is called, and he dies at the nursing home the next day.
What if Mr. A didn't have that form? Chances are the paramedics would have been called when he was found unresponsive, and he would have been taken to the local emergency department. It might have taken a while to contact his family to confirm the DNR (do not resuscitate) order. In the interim, aggressive measures may have been used.
You might be wondering how the POLST is different from an advance directive. Both of them are legal documents. However, the advance directive is not a physician's order. It is often vague and open to interpretation.
It must be remembered that the effectiveness of the POLST system is not just about filling out a form. It is about having that conversation with patients to know what they want and value. Most states have their forms in multiple languages.
Does your state have the POLST system yet? Check the POLST Website to find out and get information on how to get involved. The Coalition for Compassionate Care of California has more information on how to have the conversation with patients.
What is your experience with the POLST system in your community?
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