# 178 The National Polst Paradigm Initiative, 2nd Edition


Author(s): Judy Citko, JD, Alvin H Moss MD, Margaret Carley RN, JD, and Susan Tolle MD

Background     One barrier in the treatment of seriously-ill and dying patients has been the inability to develop a system by which a patient’s preferences for life-sustaining treatment are both documented and honored across different care sites. Regional and statewide programs have tackled this problem with variable success. Originally started in Oregon in 1991, the Physician Orders for Life Sustaining Treatment (POLST) Program creates a coordinated system for eliciting, documenting, and communicating the life-sustaining treatment wishes of seriously-ill patients. Programs with the essential core elements of POLST are developing in the majority of states. Although different states use different names, the program is universally referred to as the POLST Paradigm Program. This Fast Fact will review key elements of the POLST Paradigm Program.

The Paradigm   The POLST Paradigm was developed as a standardized, advance care planning document to be completed by health care professionals, together with a patient or surrogate decision-maker. The POLST form translates the values expressed in an advance directive into immediately active medical orders which do not require interpretation or further activation. POLST aims to provide continuity of care for patients according to their preferences across all care settings (e.g. hospitals, hospice, long-term care and home), and is transferred with the patient throughout the health care system. In each region or state, local leaders have presented widespread education to support its application across the spectrum of health care settings.
The Form    The form is brightly colored to facilitate identification and is divided into several sections:
  • CPR decision: Resuscitate or Do Not Resuscitate (DNR).
  • Medical intervention decisions: comfort measures vs. limited additional interventions vs. full treatment.
  • Medically administered nutrition: none vs. defined trial period vs. long-term use.
  • Health care professional signature: patient/surrogate signature is strongly recommended or required, depending on the state or region.
How It Works    POLST is designed for seriously-ill patients, or those who are medically frail, regardless of their age. Completion of the POLST form is voluntary. The health care professional turns the patient's values (expressed personally through conversation, and/or an advance directive, or by the patient's legal representative if the patient lacks decision-making capacity) into actionable medical orders. The orders are valid when signed by a physician (or NP/PA depending on individual state regulations). Many state/regional POLST programs also require the patient’s or legal agent’s signature to make the form valid. A copy of the POLST form is included in the medical record while the original remains with the patient as they move across settings of care.
Effectiveness     Data from completed research projects related to POLST are available on the POLST website (www.polst.org). Key findings indicate that patients’ values are accurately reflected in the orders, that the orders are followed by first responders, that life-sustaining treatment orders beyond CPR (e.g. artificial nutrition) are useful to guide care consistent with the patient’s wishes, and that implementation can evolve to become a standard of care in a community, region, or state.
State/Regional Initiatives     Numerous communities and states are developing or have implemented programs similar to Oregon’s with the guidance of the National POLST Paradigm Task Force. The names of endorsed programs include: Medical Orders for Life Sustaining Treatment or MOLST (New York); Medical Orders for Scope of Treatment or MOST (North Carolina); POLST (California, Hawaii, Oregon, Wisconsin, Washington state); and Physician Orders for Scope of Treatment or POST (West Virginia, Tennessee).
Resources     The POLST website has: sample downloadable forms, educational materials and videos; a map of states and regions using the form, along with contact information; a description of the core elements of a POLST Paradigm Program; and information on how to build a coalition of health care professionals to start a POLST Paradigm Program. A sample of most materials is available at no cost to help facilitate development of other POLST paradigm programs. There may be a low cost for larger orders to help cover expenses of a state or regional program’s coordinating center. The Center for Ethics in Health Care at Oregon Health & Science University coordinates the national initiative.
1.     Physician Orders for Life-Sustaining Treatment Paradigm. Available at: http://www.polst.org.  
  1. Tolle SW, Tilden VP, Dunn P, Nelson C. A prospective study of the efficacy of the physician orders for life sustaining treatment. J Amer Ger Soc. 1998; 46:1097-1102.
  2. Hickman SE, Hammes BJ, Moss AH, & Tolle SW. Hope for the future: achieving the original intent of advance directives. The Hastings Center Report Special Report. 2005; 35(6—Suppl):S26-S30.
4.     Hickman SE, Nelson CA, Perrin NA, Moss AH, Hammes BJ, Tolle SW. A comparison of methods to communicate treatment preferences in nursing facilities: traditional practices versus the physician orders for life-sustaining treatment program.   J Amer Ger Soc. 2010; 58:1241-1248.
Author Affiliations: Coalition for Compassionate Care, Sacramento CA (JC); West Virginia University, Morgantown, WV (AHM); Oregon Health & Science University, Portland, OR (MC, ST).
Fast Facts and Conceptsare edited by Drew A Rosielle MD, Palliative Care Program, University of Minnesota Medical Center – Fairview Health Services, and are published by the End of Life/Palliative Education Resource Center at the Medical College of Wisconsin. For more information write to: rosi0011@umn.edu. More information, as well as the complete set of Fast Facts, are available at EPERC: http://www.mcw.edu/eperc.   Readers can comment on this publication at the Fast Facts and Concepts Discussion Blog (http://epercfastfacts.blogspot.com).
Version History: 1st edition written by Patrick Dunn, Alvin H Moss, and Susan Tolle published April 2007. Revised and 2nd edition published September 2010. 
Copyright/Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Citko J, Moss AH, Carley M, Tolle S. The National POLST Paradigm Initiative, 2nd Edition. Fast Fact and Concepts. September 2010; 178. Available at: http://www.eperc.mcw.edu/fastfact/ff_178.htm.   
Disclaimer: Fast Facts and Concepts provide educational information. This information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Facts cite the use of a product in a dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.


ACGME Competencies: Systems Based Practice

Keyword(s): Ethics, Law, Policy Health Systems