Capturing Treatment Preferences for End-of-Life Care

This fact sheet was updated in July 2016 to reflect new POLST programs and updated endorsements from the National POLST Paradigm Task Force.

People with serious illnesses or frailty often receive treatment not aligned with what they want, in part because they haven’t discussed or documented their treatment preferences, or the documentation cannot be located when it’s needed. The Physician Orders for Life-Sustaining Treatment (POLST)¹ form helps address this problem by effectively capturing people’s wishes and making these preferences accessible to health care professionals as medical orders that are honored throughout the health care system.

What is POLST?

Using an approach known as the POLST Paradigm, health care professionals and individuals engage in an informed, shared decision-making process to elicit, document, and honor the patient’s treatment wishes. The process results in a medical order signed by the health care professional and, in many states, by the individual or a legally authorized surrogate as well.

How does POLST differ from advance care directives?

These forms complement one another, and both play important roles in advance care planning, but POLST forms and advance directives differ in several ways:

• A POLST form is not for everyone. Unlike advance directives, these forms are intended only for seriously ill or frail individuals whose condition is such that their doctors would not be surprised if they died within the next 12 months. A study of the form in the Oregon POLST registry found that the median time between completion of a POLST form and death is 6.4 weeks and that more than half of all forms were completed in the final two months of life.²
• Advance directives are designed to be completed before any serious illness and may specify the general extent of treatment measures someone prefers. The POLST form is completed once someone is seriously ill or frail, allowing that person to choose specific treatment options—such as CPR, intubation, and artificial nutrition—in light of their current condition.³
• POLST forms are immediately actionable medical orders that are followed by emergency medical service professionals. In contrast, advance directives do not give orders to emergency medical services and must be interpreted by a physician before they are determined to be in effect.
• Additionally, POLST forms are designed to physically stay with the patient or be included in the patient’s electronic health record or state registry where they will be easily available in an emergency.

The POLST Paradigm has several core elements, including:⁴

• Completing POLST forms must always be voluntary.
• It is imperative that the process involve informed, shared decision-making between individuals and health care providers. 
• Forms need to be portable and follow individuals across care settings.
• People are able to express their personal goals and values in choosing treatment options from a spectrum that ranges from the full course of treatment to comfort care—and then to have these wishes honored.
• POLST orders address an individual’s current medical condition and are revised accordingly as either that condition or the person’s treatment preferences change. One study found that POLST orders do change over time, with data indicating that people usually request fewer treatments as they get closer to death.⁵

The benefits of POLST

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 treatment preferences6 but also does so more accurately than traditional advance directives for individuals with serious illness or frailty.⁷ Individuals with POLST orders reflecting a preference for comfort measures proved less likely to receive life-sustaining medical intervention compared with those who had either full treatment orders or no POLST orders.⁸

A 2006-07 survey of hospices in West Virginia, Oregon, and Wisconsin found that POLST was useful in preventing unwanted medical care and for initiating conversations about treatment preferences. The survey also found that providers respected treatment limitations specified in POLST documents 98 percent of the time and that no patients received unwanted CPR.⁹ A study of nursing home residents with POLST orders for Do Not Resuscitate and Comfort Measures Only found that none received unwanted CPR, intensive care unit services, or ventilator support.¹⁰ POLST can also help people receive desired treatment—a 2014 study of forms in the Oregon POLST registry found that 33.1 percent of forms contained orders for limited or full treatment.¹¹ The earlier three-state survey of hospices found that POLST forms for 78 percent of patients contained one or more orders for life-sustaining treatment.¹²

Next steps

Most state POLST Paradigm programs rely on motivated volunteers with few resources to support development. Instituting federal or state funding could:

• Catalyze program development in the two states without a POLST Paradigm program and the 29 states with developing programs.
• Support education to increase awareness and proper use of POLST Paradigm programs among health care professionals and the public.
• Ensure that all POLST Paradigm programs follow the nationally recognized standards established by the National POLST Paradigm Task Force and that they are based on research, quality assurance, and evidence-based information.

The bipartisan Personalize Your Care Act 2.0, introduced in 2016 in the U.S. House of Representatives, would instruct the U.S. Department of Health and Human Services to provide grant funding to accomplish many of these goals. Legislation such as this is an important step in ensuring that the treatment preferences of people who are seriously ill and frail are competently discussed, recorded, and honored throughout the health care system.

Endnotes

1. POLST is known by many names, including MOLST (Medical Orders for Life-Sustaining Treatment), MOST (Medical Orders for Scope of Treatment), POST (Physician Orders for Scope of Treatment), LaPOST (Louisiana Physician Order for Scope of Treatment), COLST (Clinician Orders for Life-Sustaining Treatment), IPOST (Iowa Physician Orders for Scope of Treatment), SMOST (Summary of Physician Orders for Scope of Treatment), TPOPP (Transportable Physician Order for Patient Preference), and WyoPOLST (Wyoming Provider Orders for Life-Sustaining Treatment). For simplicity, the term POLST is used when referring to POLST forms or programs in general.
2. Dana Zive et al., “Timing of POLST Form Completion by Cause of Death,” Journal of Pain and Symptom Management 50, no. 5 (2015): 650–58, http://dx.doi.org/10.1016/j.jpainsymman.2015.06.004.
3. Judy Citko et al., “Fast Facts and Concepts #178: The National POLST Paradigm Initiative,” Palliative Care Network of Wisconsin, http://www.mypcnow.org/blank-k2dh9.
4. National POLST Paradigm, “What Is POLST?” accessed July 2, 2015, http://www.polst.org/about-the-national-polst-paradigm/what-is-polst.
5. Zive et al., “Timing of POLST Form Completion by Cause of Death.”
6. Erik K. Fromme et al., “Association Between Physician Orders for Life-Sustaining Treatment for Scope of Treatment and In-Hospital Death in Oregon,” Journal of the American Geriatrics Society 62, no. 7 (2014): 1246–51, doi:10.1111/jgs.12889.
7. Sandra L. Pedraza et al., “POST Forms More Than Advance Directives Associated With Out-of-Hospital Death: Insights From a State Registry,” Journal of Pain and Symptom Management 51, no. 2 (2016): 240–46, doi:10.1016/j.jpainsymman.2015.10.003.
8. Susan E. Hickman et al., “A Comparison of Methods to Communicate Treatment Preferences in Nursing Facilities: Traditional Practices Versus the Physician Orders for Life-Sustaining Treatment (POLST) Program,” Journal of the American Geriatric Society 58, no. 7 (2010): 1241–8, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2963454/.
9. Susan E. Hickman et al., “Use of the Physician Orders for Life-Sustaining Treatment (POLST) Paradigm Program in the Hospice Setting,” Journal of Palliative Medicine 12, no. 2 (2009): 133–41, http://dx.doi.org/10.1089/jpm.2008.0196.
10. Susan Tolle et al., “A Prospective Study of the Efficacy of the Physician Order Form for Life-Sustaining Treatment,” Journal of the American Geriatrics Society 46, no. 9 (1998): 1097–1102.
11. Fromme et al., “Association Between Physician Orders for Life-Sustaining Treatment for Scope of Treatment and In-Hospital Death in Oregon”; see also Zive et al., “Timing of POLST Form Completion by Cause of Death.”
12. Hickman et al., “Use of the Physician Orders for Life-Sustaining Treatment (POLST) Paradigm Program in the Hospice Setting.”
13. Institute of Medicine, “Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life” (2014), https://iom.nationalacademies.org/~/media/Files/Report%20Files/2014/EOL/Report%20Brief.pdf.
14. Ibid.