The National POLST Paradigm is a voluntary approach to end of life planning that emphasizes eliciting, documenting and honoring the treatment preferences of seriously ill or frail individuals using a portable medical order called a POLST Form. If a seriously ill or frail patient wants to use a POLST Form, his/her health care professional will complete it after talking with the patient about his/her diagnosis, prognosis, treatment options, and goals of care. In the event of a medical emergency, when time is of the essence for medical decision-making, the POLST Form serves as an immediately available and recognizable order set in a standardized format. Emergency personnel follow the POLST form medical order to provide treatments the patient wanted during an emergency, potentially avoiding unwanted hospitalizations and emergency department visits.
Q: Can you tell us about the National POLST Paradigm and its history?
A: In 1991 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 process and tool for eliciting, documenting, and 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) Paradigm.
In 2004, the National POLST Paradigm Task Force was established to set quality standards for POLST forms and programs and to assist states in developing the POLST Paradigm, which it still does today. At this time, all 50 states and Washington DC have taken some step to implement the POLST Paradigm. More information on state programs is available here.
Q: We’re hearing more and more about advance care planning documents, namely Advance Directives. What differentiates a POLST form from an Advance Directive?
A: The POLST Paradigm occupies a very unique niche within advance care planning and the biggest challenge is helping the public and health care professionals appreciate the difference between “advance care planning”, “advance directives” and the POLST Paradigm.
“Advance care planning” generally refers to decisions made by an individual to share general or specific treatment wishes in advance of a medical crisis. Both advance directives and POLST forms are advance care plans.
An “advance directive” is often used as the generic term for legal documents that provide general treatment wishes and may or may not appoint a surrogate. All adults should have an advance directive. These documents do not provide medical orders; however, they provide general information about what types of treatment the patient wants during some unknown medical crisis.
The POLST Form is a portable medical order that is only intended for individuals (of any age) who are seriously ill or frail and near the end of life. In the event of a medical emergency, when time is of the essence for medical decision-making, the POLST Form serves as an immediately available and recognizable order set in a standardized format. This aids emergency personnel in implementing patient treatment preferences as communicated to—and documented by— the patient’s health care professional in the field and gives guidance about whether the patient wanted to be transported to a hospital or not (and, at the hospital, whether the patient wanted to be in the ICU or not).
Our standard of care during an emergency is to do everything possible in an attempt to save someone’s life, unless there is a medical order to the contrary. With an advance directive, a patient will receive the standard of care until they are stabilized at the hospital and the advance directive can be reviewed; the health care team will identify the surrogate named in the document and work with that person to take the patients’ general treatment wishes and turn them into a care plan. With a POLST form, however, emergency personnel know the patient treatment wishes and will follow the orders on the form about what treatments to provide and whether or not to transport a patient.
The National POLST Paradigm has two pages that provide charts and additional information: POLST & Advance Directives and POLST & Advance Care Planning.
Q: States have been and will be attempting statewide registries. What is the value of a state POLST registry for patients and providers across the care continuum?
A: Three reasons statewide registries are valuable:
(1) They provide a pathway for emergency personnel to know what treatments a patient wanted even if the patient doesn’t have their POLST form available. Without a registry, emergency personnel must have a paper document (original, copy or fax) in order to follow POLST form orders; this puts the burden on the patient (a seriously ill or frail person) to keep his/her POLST form with them at all times. With a registry, emergency personnel can make a call and get medical orders over the phone.
(2) For states with a mandate to submit a POLST form to the registry, registries can serve as a “single source of truth”, meaning that they hold the most current version of a patient’s POLST form. Without a registry, different facilities may have different versions of a POLST form if the patient receives care in multiple places and doesn’t share updated versions of his/her POLST form.
(3) They provide opportunities for quality assurance activities, giving leaders an opportunity to review how the POLST Paradigm is being used within the state (or a facility) and how the form is being used. This information can be used to improve POLST Programs at the state and national levels.
Q: Are there plans for a nationwide POLST form that could be used to standardize POLST documentation across the country?
A: Yes, although it will be a challenge because many state POLST forms have language required to be in the form in state statute or the form language is under the control of the state department of health. In the meantime, the National POLST Paradigm encourages states to create forms similar enough to allow for reciprocity across state lines (ensuring a patient’s POLST form can be honored wherever they are during an emergency regardless of what state form they have), through its endorsement standards for POLST forms.
Amy Vandenbroucke, JD is the Executive Director of the National POLST Paradigm.