Obviously, none of us who have decided otherwise would prefer to have medical procedures done which we would have refused had we been able.  But ultimately, an emergency is just that: sometimes our wishes are not honored in the way we anticipate.  And usually, if wishes are clearly delineated and we have a Durable Power of Attorney for Health Care, and a POLST form filled out and signed, those wishes are respected.  Thankfully, if an unfortunate circumstance has occurred, it can be remedied, especially if an authorized decision maker has been chosen in advance.

Here is detailed information about the POLST form,  if, when, and how  to fill it out. 

POLST INFORMATION: 

POLST, or Physician Orders for Life-Sustaining Treatment,  is a set of medical treatment orders your doctor may ask you to sign. Some people have questions about the form and wonder if they should fill one out, and if so, when and how. Others want additional information about the options outlined on the form. Still others wonder how the POLST compares to their Advance Directive (also called a Health Care Directive) and if they still need a Durable Power of Attorney for Health Care.

The following information contains an Overview of the POLST form, Step-by-Step Instructions, and a Resource Page for further information.

QUESTIONS AND ANSWERS & INSTRUCTIONS FOR FILLING OUT THE FORM

The POLST Form is a Physician Orders for Life- Sustaining Treatment your doctor may ask you to sign. The POLST is  a set of medical treatment orders and a menu of possible medical interventions. 

According to the Washington State Medical Association (WSMA):  "POLST is not for everyone. POLST is designed for seriously ill individuals, or those who are in very poor health*, regardless of their age." Washington State was on of the first states in the country to establish a POLST form and has good summary information which also applies to other states. 

Again,  according to the WSMA, "The Portable Orders for Life Sustaining Treatment (POLST) form is a "portable" physician order form that describes the patient's care directions. It represents a way of summarizing wishes of an individual regarding life sustaining treatment identified in an advanced directive such as a Health Care Directive or Durable Power of Attorney for Health Care. It is intended to go with the patient from one healthcare setting to another and includes the following:

• Patient wishes for resuscitation
• Medical interventions
• Antibiotics
• Artificial feedings"

 The Washington State warning re POLST forms not being appropriate for everyone, is a helpful reminder.  POLST forms refusing treatment such as CPR and respirators and are not recommended people in good health as it may limit your ability to have life-saving treatment in an urgent or emergent situation.  

Initially created for medics responding to 911 calls, the POLST form serves as “headline news” about whether a seriously ill or dying patient wants CPR (cardiopulmonary resuscitation) or not. Because advance directives are varied and not always immediately available to medics responding to an urgent call, the POLST was developed as a stop-gap portable mechanism to assure end- of-life wishes were honored during the initial 911 assessment and the drive between the patient’s home and the hospital.

When first developed, the form was limited to those “whose health care professional wouldn’t be surprised if they died within a year.” In the decades since, POLST use has expanded to “those who are seriously ill or in poor health.” 

Most states now have a POLST and such forms are widely used as a set of treatment (or no treatment) orders by medics, physicians, and hospitals. When confronted with a request to fill out a POLST, many people have questions. The following information is a compendium of questions and answers arising from the POLST form and from Advance Directive discussions.

Good question. The POLST is not intended to replace an Advance Directive; rather it was created and is intended as a complementary document for those who are seriously or terminally ill or in poor health. The POLST is a voluntary form summarizing a person’s wishes in the form of clear and specific medical orders. An Advance Directive, also known as a Living Will, is also voluntary, but often recommended for everyone, regardless of age or health status.

There are a variety of Advance Directives which contain a DPOA. One of the best, Five Wishes, was developed by a lawyer who worked with Mother Teresa in Calcutta. It is straight forward, easy-to-understand, and provides details how you want to be cared for at the end of life.

The intent of an Advance Directive is to make sure your wishes about life-sustaining care or treatment are honored. An Advance Directive does this in two ways.

1) An Advance Directive often includes a Durable Power of Attorney for Health Care (DPOA), which gives someone you designate in advance the power to make certain medical decisions for you if you are unable to make your own medical decisions. The person you

designate is known as your Legal Health Care Decision-Maker. The DPOA is the legal document by which you designate that person to make medical decisions for you. This is probably the single most important way to make sure your wishes are honored.

In the event of a medical emergency in which you can’t speak for yourself, your health care decision-maker, along with your physician, can decide what medical interventions, if any, are in your best interest. It’s good to speak to your health care decision- maker in advance about what’s important to you, what medical interventions you think you might want or not want. However, since no one knows exactly what kind of medical crisis may occur in your future, it’s crucial to have someone you trust to discern your wishes, speak on your behalf, and advocate for you.

2) An Advance Directive describes in writing your thoughts on medical care and treatment decisions. This part of an Advance Directive describes your current wishes on care and treatment in the event of a serious or terminal illness or injury.

Please allow your designated medical decision-maker the flexibility to modify your written guidelines, depending on circumstances. For example, if you are in a car accident and need CPR and artificial respiration temporarily but are expected to make a complete recovery, you’d hate for your advance directive to state NO CPR/NO ARTIFICIAL RESPIRATION. This could prevent you from getting the emergency, life-saving care you need to recover. If, on the other hand, you’ve reached advanced age and are ill and frail or have been diagnosed with terminal cancer with a limited life expectancy, it would be futile to do CPR and aggressive medical interventions. Instead, most likely you’d prefer comfort measures and quality of life.

For a non-medical person, the medical world can be not only confusing, but frightening. Most people worry about making the “wrong” decisions or not making the right ones. So what’s a person to do?

First, find someone you trust to make your decisions when you can’t. Create a Durable Power of Attorney for Health Care so the person you trust can do just that.

Second, complete an Advanced Directive or Living Will. Write some guidelines about what you think you may or may not wish in terms of CPR and other medical and treatment decisions. Make sure you write that your designated medical decision-maker is empowered to make medical decisions and to advocate for you in light of the particular circumstances.

If you have a serious medical condition or are in very poor health and have discerned you do want to complete a POLST, feel free to do so. Please see the attached information: How to Complete Your POLST Form.

The POLST is a bright green form which can be obtained or ordered on-line at your state’s Medical Association or Department of Health web site. Most state medical associations also have information about the POLST as well. The National POLST Paradigm has general information about the POLST form as well as links to each states form.

“POLST Is a way for you to express end of life treatment wishes such as whether you would want:

 (1) emergency personnel to attempt cardiopulmonary resuscitation (CPR) in the event that you were found unconscious, not breathing, or without a pulse; 

(2) to go to the hospital, to be put on a breathing machine (if necessary), or if you want to be made comfortable where you are.”

The National POLST Paradigm

These instructions address Washington State’s bright green Physician Orders for Life-Sustaining Treatment/POLST form. Other states, such as New York and California, have bright pink forms. New York’s form is called MOLST (Medical Orders for Life Sustaining Treatment.) 

Since most states have similar forms and subject matter, How to Complete a POLST Form will also provide helpful information to residents of any state. Non- Washington residents should refer to www.polst.org for copies of your state’s POLST form. The forms vary somewhat but content is similar.

Please note: A POLST form is a “physician order to help give seriously ill patients more control over end-of-life care.” https://wsma.org/POLST It is intended for those who are in poor health or those of advanced age who would like to avoid the use of “extraordinary measures” such as CPR or a respirator. It was not created for use by healthy individuals.

INTRODUCTION of POLST form. This section has space for your name, date of birth, and last 4 numbers of your social security number.

Medical Conditions and Patient Goals. Under this section, please fill out any illnesses or medical conditions you have and indicate the severity of these illnesses or conditions along with any specific goals. Also include medication allergies and the DPOA-related information bolded below.

For example, you could write something like: “Mild osteoarthritis; history of asthma; breast cancer.” Your goal in that case might be: “Full treatment unless medical futility is clear.” Or, if your circumstances are medically dire, you could write: “End-stage, terminal pancreatic cancer. Goal: Comfort Focused Treatment Only. In both cases, write: Please consult with my DPOA who is empowered to make medical decisions and advocate for me in light of specific medical circumstances.” Then write the DPOA’s name and phone number.

This section only applies if you have no pulse and are not breathing. The first box is: Attempt Resuscitation/CPR. The second box is: Do Not Attempt Resuscitation/DNAR (Allow Natural Death).

Healthy individuals should not complete a POLST. If you choose to do so anyway, please check the box entitled: Attempt Resuscitation/CPR. This means medics will attempt to save your life with aggressive medical measures and CPR. This is the appropriate medical course for an individual without serious illness who is not of very advanced age and frailty. It is also the best choice for someone who does have a serious illness or is of advanced age but who has a chance of recovery or of benefiting from further medical treatment. If such medical treatment later turns out to be medically futile/without chance of meaningful recovery, your DPOA can work with doctors to discern the best medical and comfort-focused course of action for you.

Most people who are terminally ill choose to check the box entitled: Do Not Attempt Resuscitation/DNAR (Allow Natural Death.) Many people with serious health conditions such as advanced Alzheimer’s, incurable debilitating diseases, or those of advanced age, also choose DNAR. Note: Research shows CPR done on frail elderly individuals and those with severe osteoarthritis is more likely to cause bone breakage, punctured lungs, and rib fractures. In those who are very elderly or seriously ill, CPR is usually not effective, can be harmful, and does not result in the person being able to leave the hospital.   

This section applies if you have a pulse and/or are breathing. The section has three boxes, one of which should be checked. The first box is: Full Treatment. The second box is: Selective Treatment. The third box is: Comfort-Focused Treatment.

Please remember that these choices need not be permanent. These are your best, first choices given what you know about your health at this moment. Your DPOA, whose contact information you’ve included under Medical Conditions/Goals, will be involved in your care and treatment decisions. 

Your DPOA will stand ready to help medical staff transition you from Full Treatment to Selective Treatment or Comfort-Focused Treatment should your condition change for the worse or decline precipitously. Conversely, should your condition improve beyond medical expectations and meaningful recovery become an option, you could be moved up to a higher level of medical treatment or care.

With that in mind, here is a summary of each of these areas:

Full Treatment: with the primary goal of prolonging life by all medically effective means. Care in this section includes care described under Selective Treatment and under Comfort Focused Treatment. It includes using intubation (commonly referred to as a respirator), advanced airway interventions, mechanical ventilation, and cardioversion. This care would include transfer to a hospital, most likely an intensive care unit.

It usually refers to a series of aggressive medical treatments with a goal of eventual recovery. Some people with serious illnesses who wish aggressive/active treatment, at least temporarily, choose this option, while others prefer one of the options described below. The “full treatment” choice gives the patient an option of recovery while the severity of her medical condition is being evaluated and treated. Examples of sudden medical events needing full treatment might include a heart attack, automobile accident, or an unexpected stroke requiring urgent treatment to make recovery possible.

Selective Treatment: with the goal of treating medical conditions while avoiding burdensome measures. This section includes the use of medical treatment, IV fluids, and cardiac monitors as indicated. It does not include intubation (the use of a respirator/ventilator) but may include the use of less invasive airway support, CPAP or BIPAP (respiratory comfort treatments). A transfer to a hospital may be necessary but intensive care units are to be avoided if possible. Many people with serious illnesses choose this option. Some people who have a life-limiting illness but are not actively terminal choose this as well. It provides options for the treatment of temporary dehydration and allows IV medications or cardiac monitoring as needed.

Comfort-Focused Treatment: with a primary goal of maximizing comfort. This section focuses on the relief of pain and suffering. The use of oxygen and other comfort measures are offered. Under this section, the patient prefers no hospital transfer although medics can contact a physician to determine if a hospital transport is needed to provide adequate comfort. This choice is generally made by people or for people with advanced terminal illness, end-stage dementia, or other medical conditions without a hope of meaningful recovery. Oftentimes, under such circumstances a person is at home with hospice services or in a facility with access to medical providers and comfort-care provisions.

The bottom of Section B offers a space for Additional Orders. Current medications and doses can be written in this space. (You may need to attach additional orders or a complete medication list.)

This section includes space for the signatures of a patient, a physician, or if the patient is incapacitated, a DPOA. This section also contains two boxes at the bottom. The first box should be checked if the person has a Health Care Directive (Living Will/Advanced Directive). The second box should be checked if the person has a Durable Power of Attorney for Health Care.

Both boxes should be checked if the person has both. This section “encourages all advance care planning documents to accompany POLST.” Please attach your DPOA and Advance Directive to the POLST.

Section D provides some choices which are important but not usually urgent.

The first section under D regards Antibiotics. It contains two check boxes. Check the first box if you wish medical personnel to “Use antibiotics for the prolongation of life.” In contrast, check the second box if you wish to instruct medical personnel, “Do not use antibiotic except when needed for symptom management.”

Most people choose “use of antibiotics for the prolongation of life.” Checking the first box allows, for example, use of antibiotics to treat pneumonia or a urinary tract infection or wound. If a person is actively terminal or very seriously ill, and antibiotics have been tried and are no longer effective, the person will sometimes check the POLST box instructing medical personnel “Do not use antibiotics except when needed for symptom management.” Generally speaking though, it may be best to choose the first option, “Use antibiotics for the prolongation of life, and then allow your DPOA to modify that option as necessary should antibiotics prove to be ineffective, should they become burdensome, or should you be actively dying.

The next section under Section D is: Medically Assisted Nutrition: This area notes: “Always offer food and liquids by mouth if feasible.” The first check box states, No medically assisted nutrition by tube. Those with advanced terminal illness and those who can no longer process food or fluids choose this. During the dying process, a person’s heart, lung, and kidney function decreases and the ability to swallow is lost. When this happens, offering IV hydration or nutrition by food is burdensome vs. beneficial: it can make a person die sooner and more uncomfortably.

The second check box states, Trial period of medically assisted nutrition by tube. This choice is favored by those who want to give medical recovery a chance but prefer not to receive long-term medically assisted nutrition. The goal here can be worded as: Please allow my DPOA to determine if nutrition by tube is beneficial to me.”

The third check box states, Long term medically assisted nutrition by tube. This option is chosen by those who would like long term nutrition support if they are unable to swallow. The goal can be worded as above. Please note: As above, should the active dying process occur, such long term medically assisted nutrition via tube should be discontinued.

The final area under Section D is Additional Orders. This section provides space in which to write information about dialysis, blood products, and implanted cardiac devices. An area for patient/physician signatures follows, then a space for Directions for Health Care Professionals. There is also an area for voiding or completing a new form. You can void and revise your DPOA at any time. Please notify your MD to destroy the previous document and replace it with the updated one.

The decision whether or not to complete a POLST form is highly personal and always voluntary. If you have ongoing questions, please discuss these with your DPOA or health care professional.

“POLST is a process beginning with conversation between you and your doctor, nurse, or physician assistant. The conversation should include information about your current medical condition and what is important to you. You may choose to have a POLST form after this conversation—you should never be forced to have a POLST form.”

The National POLST Paradigm

POLST RESOURCES

The following are a few resources representing both opinions. The best solution is for each person to review the available material, inform their conscience, and discern if they wish to complete a POLST form or not, and if so, how they wish to complete the form.

National POLST Paradigm: This program advocates in favor of POLST completion and has information for patients and health care providers on the POLST form and provides resources for residents of each state. https://polst.org: Non-Washington residents should refer to www.polst.org for copies of your state’s POLST form.

California POSLT Forms: 

The California POLST is bright pink vs bright green. 

· https://emsa.ca.gov/DNR_and_POLST_Forms

New York Information re MOLST Forms:

· In New York, the POLST (Physician Orders for Life Sustaining Treatment) equivalent form is called MOST, for Medical Orders for Life Sustaining Treatment

· New York’s form is also bright pink.

· https://www.health.ny.gov/professionals/patients/patient_rights/molst

Oregon Information re POLST forms:

· https://oregonpolst.org/advance-directives

Washington State Medical Association: The WSMA has worked with the Washington State Hospital Association and the Department of Health to provide POLST related education. All favor the use of POLST forms and provide access to downloading the form.

· https://wsma.org/POLST: PDF’s of the POLST form and brochure are available here.