Understanding POLST & Advance Directives
How Is POLST Used in Advance Care Planning?
POLST forms provide specific medical orders for patients with advanced illness or frailty. POLST forms should only be completed after the health care professional has talked with the patient about:
patient’s diagnosis and prognosis
treatment options including the benefits and burdens of each
patient’s goals of care
Health care professionals should review (and update if appropriate) a patient’s POLST form when:
the patient is transferred from one care setting or care level to another;
there is a substantial change in the patient’s health status; or
the patient’s treatment preferences or goals of care change.
Patients are provided original copies of the form (to be kept on the fridge or in the medicine cabinet) and a copy is kept in their medical record and, if the patient hasn’t opted out, in the Oregon POLST Registry.
POLST forms and advance directives serve different purposes but can be complementary for advance care planning.
POLST forms provide medical orders during an emergency that can be followed by EMS. Advance directives cannot be followed by EMS.
Health care professionals complete the POLST form after having a conversation with the patient about his/her diagnosis, prognosis, treatment options and goals of care.
Why Isn’t POLST an Advance Directive?
There are many differences but four material differences are:
POLST is appropriate only for a limited patient population: for patients who have advanced illness or frailty. Advance directives are for all competent adults.
POLST only provides specific medical orders based on the patient’s goals of care given their current state of health; POLST provides information about treatment the patient would or would not want today based on his/her diagnosis, prognosis, current treatment options and goals of care. Advance directives provide general wishes about future care and generally require interpretation of those wishes to apply them to the immediate medical circumstances of the patient.
Emergency medical service (EMS) personnel cannot follow an advance directive during an emergency but they can follow a POLST form. This is because POLST is a medical order. This then allows patient treatment preferences to be known further upstream during a medical emergency; POLST forms are followed at the scene whereas advance directives aren’t even reviewed until after the patient arrives at to the health care facility.
POLST forms require a physician (M.D. or D.O.), nurse practitioner, physician assistant, or doctor of naturopathy signature; this means the health care professional is- and should be- part of the advance care planning conversation. A health care professional may be unaware a patient even has an advance directive.
What Is an Advance Directive?
Advance directives are legal documents that all competent adults should have. Patients should use them to long-term advance care planning, identifying a surrogate/health care decision-maker, and for generally documenting medical treatments they would want if they lack capacity.
Why Is an Advance Directive Not Enough?
While the POLST program supports the completion of advance directives, clinical experience and research demonstrate that advance directives are not sufficient to ensure that those who have an advanced illness or frailty will have their preferences for treatment honored. A POLST form must also be completed to assure patients that they will receive the treatments they want and avoid treatments they do not want.
Additionally, over the last couple of decades it has become clear that advance directives alone aren’t enough:
They are difficult to read and understand, using terms that only those with high medical literacy truly understand;
They are not readily available or easily found during an emergency;
They only provide vague patient instructions generally requiring interpretation; and
Health care professionals lack of confidence in patient’s understanding options available (and options selected) on document, that options selected are still current preferences, or that document produced is most recent version.