POLST Form Instructions

POLST Form Instructions

Physician Orders for Life-Sustaining Treatment

WHAT IS POLST?

POLST (Physician Orders for Life-Sustaining Treatment) is a standardized medical order form that documents a patient's wishes regarding specific life-sustaining treatments. Unlike advance directives, POLST is a medical order signed by a healthcare provider that must be followed by healthcare professionals.

Other Names for POLST:

• MOLST (Medical Orders for Life-Sustaining Treatment) - NY, NC, WV, and others
• TPOPP (Transportable Physician Orders for Patient Preferences) - TN
• COLST (Clinician Orders for Life-Sustaining Treatment) - CO
• POST (Physician Orders for Scope of Treatment) - WV
• MOST (Medical Orders for Scope of Treatment) - NC
• LaPOST, IPOST, etc. (varies by state)

WHO SHOULD HAVE A POLST?

POLST is appropriate for individuals who:

☐ Have a serious illness or frailty
☐ Would not be surprised if they died within one year
☐ Are in a nursing home or receiving hospice care
☐ Have advanced chronic disease
☐ Have had multiple hospitalizations
☐ Want to specify their treatment preferences
☐ Are nearing end of life

POLST is NOT intended for healthy individuals. Young, healthy adults should complete an advance directive but typically do not need a POLST.

POLST VS. ADVANCE DIRECTIVE

POLST complements but does NOT replace an advance directive. Both documents serve different purposes.

SECTION 1: UNDERSTANDING POLST SECTIONS

Most POLST forms contain the following sections:

Section A: Cardiopulmonary Resuscitation (CPR)

This section applies ONLY if the patient has no pulse and is not breathing.

Options typically include:

☐ Attempt Resuscitation/CPR
Full resuscitation efforts including chest compressions, defibrillation, intubation, and resuscitation medications.

☐ Do Not Attempt Resuscitation (DNAR)/Allow Natural Death
No CPR. Allow natural death. Focus on comfort care.

Section B: Medical Interventions

This section applies when the patient has a pulse and/or is breathing but is seriously ill.

Options typically include:

☐ Full Treatment
Use all available medical interventions, including hospitalization, ICU care, intubation, and mechanical ventilation.

☐ Selective Treatment / Limited Interventions
Use some medical interventions (e.g., IV fluids, antibiotics, hospitalization) but avoid intubation and mechanical ventilation. May include non-invasive ventilation (BiPAP, CPAP).

☐ Comfort-Focused Treatment / Comfort Measures Only
Focus on comfort and symptom management. Avoid hospitalization unless needed for comfort. Do not use life-prolonging treatments.

Section C: Artificially Administered Nutrition

This section addresses feeding tubes (not eating by mouth).

Options typically include:

☐ Long-term artificial nutrition (including feeding tubes)

☐ Trial period of artificial nutrition

☐ No artificial nutrition

Note: This section addresses tube feeding only. Offering food and fluids by mouth should always be done if the patient can swallow safely.

Section D: Discussed With (Documentation)

This section documents who participated in the conversation:

☐ Patient (with decision-making capacity)
☐ Healthcare agent (named in advance directive)
☐ Court-appointed guardian
☐ Parent of minor
☐ Other legally authorized representative

Section E: Signatures

Required signatures typically include:

☐ Physician, Nurse Practitioner, or Physician Assistant signature
☐ Patient or authorized representative signature

SECTION 2: HOW TO COMPLETE A POLST

Step 1: Determine Appropriateness

☐ Is the patient seriously ill or frail?
☐ Would you not be surprised if the patient died within one year?
☐ Does the patient want to document treatment preferences?

If yes to these questions, POLST is appropriate.

Step 2: Obtain the State-Specific Form

☐ Get the official POLST form for your state
☐ Forms are typically available from:

• State POLST program website
• Healthcare providers
• Hospitals and nursing homes
• Hospice organizations

State POLST Program Contact:

Website: _______________________________________________

Phone: _______________________________________________

Step 3: Have the Conversation

A qualified healthcare professional should discuss:

☐ The patient's current health status and prognosis
☐ Goals of care
☐ Values and priorities
☐ Each treatment option on the form
☐ Likely outcomes of each option
☐ Alignment of treatment options with patient's goals

Step 4: Complete the Form

☐ Mark selections in each section based on discussion
☐ Ensure selections are consistent with each other
☐ Healthcare provider signs the form
☐ Patient or authorized representative signs

Step 5: Distribute and Display

☐ Original stays with the patient (at bedside, on refrigerator, etc.)
☐ Copy in medical record
☐ Copy to each healthcare provider involved in care
☐ Copy to healthcare facility (nursing home, hospice)
☐ Make form easily visible and accessible

SECTION 3: STATE-SPECIFIC INFORMATION

3.1 Your State's POLST Program

State: _______________________________________________

Program Name (POLST/MOLST/other): _______________________________________________

Official Form Available at: _______________________________________________

State Program Contact: _______________________________________________

3.2 Who Can Sign in Your State

Practitioners who can sign:
☐ Physician (MD/DO)
☐ Nurse Practitioner (NP)
☐ Physician Assistant (PA)
☐ Other: _______________________________________________

3.3 Form Requirements

☐ Specific form color required: _______________
☐ Specific paper size required: _______________
☐ Witness required: ☐ Yes ☐ No
☐ Electronic version available: ☐ Yes ☐ No
☐ Registry available: ☐ Yes ☐ No

SECTION 4: COMMON TREATMENT COMBINATIONS

Scenario 1: Full Treatment

Appropriate for: Patients who want all available treatments

Scenario 2: DNR + Selective Treatment

Appropriate for: Patients who want treatment for reversible conditions but not CPR

Scenario 3: Comfort Care Only

Appropriate for: Patients who prioritize comfort over life prolongation

SECTION 5: INSTRUCTIONS FOR SPECIFIC SITUATIONS

5.1 For Patients

Before completing POLST:
☐ Think about your goals - What is most important to you?
☐ Consider your values - What makes life worth living?
☐ Discuss with family - Share your wishes with loved ones
☐ Talk to your doctor - Understand your condition and options

After completing POLST:
☐ Keep the original with you (at home, in nursing facility)
☐ Give copies to family and healthcare providers
☐ Review periodically, especially if condition changes
☐ Revoke or update if your wishes change

5.2 For Healthcare Providers

Before completing POLST:
☐ Confirm patient has serious illness or frailty
☐ Verify decision-maker (patient or authorized representative)
☐ Explain diagnosis, prognosis, and treatment options
☐ Discuss goals of care
☐ Ensure understanding and voluntary decision

Documentation:
☐ Document discussion in medical record
☐ Note who participated in conversation
☐ Explain any conflicts or concerns
☐ Enter POLST in medical record or registry

5.3 For EMS/First Responders

When responding to a call:
☐ Look for POLST form (bright colored, usually on refrigerator or at bedside)
☐ Verify patient identity matches the form
☐ Follow orders as written
☐ If no POLST found, provide full treatment
☐ Contact medical direction if questions arise

SECTION 6: REVIEWING AND CHANGING POLST

6.1 When to Review POLST

☐ Annually at minimum
☐ When transferring between care settings
☐ When health status significantly changes
☐ When patient's wishes change
☐ After hospitalization
☐ At care conferences

6.2 How to Change POLST

POLST can be changed at any time by:

1. Voiding the form:
   - Write "VOID" across the form
   - Patient or representative signs and dates
   - Complete a new form if desired

2. Completing a new form:
   - New form supersedes old form
   - Destroy old copies
   - Distribute new form

6.3 Revoking POLST

The patient can revoke POLST at any time by:
☐ Verbal statement to healthcare provider
☐ Physical destruction of the form
☐ Completing a new form with different orders

SECTION 7: FREQUENTLY ASKED QUESTIONS

Q: Is POLST legally binding?
A: Yes, POLST is a medical order that healthcare providers must follow. It has the force of any other physician's order.

Q: Does POLST replace an advance directive?
A: No. POLST addresses specific treatments. An advance directive names a healthcare agent and expresses general wishes. Both are important.

Q: Can family members override POLST?
A: Generally, no. POLST represents the patient's (or authorized representative's) own decisions. Family disagreement does not change the orders.

Q: What if there's a conflict between POLST and an advance directive?
A: POLST typically takes precedence because it represents the most recent expression of the patient's wishes, signed by a physician.

Q: Does POLST apply in all states?
A: Most states have POLST programs, but forms and requirements vary. A POLST from one state may not be honored in another state.

Q: How long is POLST valid?
A: POLST does not expire but should be reviewed periodically and when the patient's condition changes.

Q: Can I have POLST without a DNR?
A: Yes. You can choose full CPR while also specifying preferences for other treatments.

SECTION 8: RESOURCES

8.1 National POLST Program

National POLST Website: polst.org

POLST Education: polst.org/education

State Program Directory: polst.org/programs-in-your-state

8.2 State POLST Resources

State Program Website: _______________________________________________

State Form Download: _______________________________________________

State Contact/Hotline: _______________________________________________

8.3 Additional Resources

☐ Advance care planning facilitator
☐ Hospice social worker
☐ Hospital palliative care team
☐ Elder law attorney

SECTION 9: PREPARATION CHECKLIST

Before the POLST Conversation

☐ Patient (or representative) has capacity to participate
☐ Patient's diagnosis and prognosis are understood
☐ Family members have been informed (if patient desires)
☐ Advance directive has been reviewed (if one exists)
☐ Healthcare agent has been identified (if patient lacks capacity)

During the POLST Conversation

☐ Goals of care discussed
☐ Each section of POLST explained
☐ Treatment options and outcomes discussed
☐ Patient/representative questions answered
☐ Selections recorded on official state form

After POLST Completion

☐ Form signed by healthcare provider
☐ Form signed by patient/representative
☐ Original placed with patient
☐ Copies distributed to providers
☐ Copy in medical record
☐ Family notified of POLST contents
☐ Review date scheduled

This document provides educational information about POLST forms. POLST is a state-specific medical order form. You must use your state's official POLST form. For questions about completing POLST, consult with your healthcare provider or your state's POLST program.