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POLST: Important Questions & Answers


Reflection from the past
“Honest Debate about End-of-Life Talk” by Charles Krauthammer
(Washington Post — August 21, 2009)
“To offer government reimbursement to any doctor who gives end-of-life counseling — whether the patient asks for it or not — is to create an incentive for such a chat….[I]t is subtle pressure applied by society through your doctor.  And when you include it in a health-care reform whose major objective is to bend the cost curve downward, you have to be a fool or a knave to deny that it’s intended to gently point the patient in a certain direction, toward the corner of the sickroom where stands a ghostly figure, scythe in hand, offering release.”

POLST is a name that stands for a form called “Physician Orders for Life-sustaining Treatment.”  The form is also called by alternative names such as MOLST, POST, MOST, etc., depending upon the state in which it is filled out.

New Jersey lawmakers introduce bill to permit registration of end-of-life care at motor vehicle agencies.
NJ Spotlight 3/9/20
The bill is a promotion of POLST forms.  It would create a registry for POLST forms and a process to allow residents coming in for a driver’s license to document wishes that would be accessible to all medical providers and emergency responders statewide.
Text of bill
More on New Jersey
More on POLST

2017 POLST bill (SB 228) proposed in Florida.
Text of SB 228

2016: MOLST bill (SB 165) proposed in Ohio.
Text of SB 165.
Analysis of SB 165.

POLST Program Legislative Comparison
(American Bar Association — February 15, 2015)
Information on POLST in 24 states.

“Study: Emergency providers often lack consensus on what patients intend when end-of-life forms come into play”
(AHC — May 4, 2015)
A new study suggests there is a lack of consensus or understanding about what patients intend when they fill out Physicians Orders for Life Sustaining Treatment (POLST) forms, and that this likely leads to patients either receiving or not receiving treatment contrary to their wishes….Researchers say that “do not resuscitate” orders are commonly misinterpreted to mean do not treat, and there are also practice and regional variations in how end-of-life care documents are interpreted.

“What Physicians and Other Healthcare Providers Need to Know Today About End-of-Life Care”
(Medscape — October 22, 2015)
End of Life Care: New CMS Reimbursement Rules
[T]here are numerous healthcare payer systems out there that essentially incentivize the completion of forms with quality financial bonuses for the institutions.  What is happening here is that a social worker — who may not have as in-depth knowledge as we do — is essentially looking at a living will and then pulling out a POLST form, checking off a box that says “DNR comfort measures only,” and having the patient sign it….[W]e are getting very good at scanning documents into our electronic health records….If it is incorrect, it is a pretty serious patient safety risk.

2014 POLST Legislative Guide
(National POLST Paradigm Task Force — 2014)
Discussion of POLST by NPPTF which supports its national implementation.

White Paper
“The POLST paradigm and form: Facts and analysis”

(Linacre Quarterly — 2013)
An extensive analysis of POLST including its origins, legal status and implementation.

For additional information about the POLST, MOLST, POST or MOST form,
enter one of those terms
into the “Search Site and/or News” box on this page.

“Model POLST Statute”
(POLST: Critical Analysis and Comment — September 27, 2013)
Intended to allow individuals to use the form to effectuate their end of life treatment preferences.  Contains suggestions that include protections against abuse and the possibility of unintended circumstances.

According to Dr. Ferdinando L. Mirarchi, Medical Director of the Deapartment of Emergency Medicine at the University of Pittsburgh Medical Center Hamot in Erie PA:

Right now, the POLST document does not equate with informed decision-making on the part of the patient.  There may even be some question of whether it equates with informed decision-making on the part of a provider….

When you look at POLST right now, there is no regulation or oversight of the whole process.  Think about it.  When I write for an aspirin for a cardiac patient experiencing an MI, I have to jump through six or seven different hoops.  In addition, there’s nursing read-backs and pharmacist oversight, not to mention real-time interaction checkers in the system.

For me to write a DNR order, for the most part, I just have to find the form.  It’s one step. People are then overly willing then to enact that form on an individual patient.
(Source:  Robert Glatter, MD, Ferdinando L. Mararchi, DO, “POLST and DNR: Misunderstandings that Confound Critical Care,” Medscape Internal Medicine, April 7, 2015)


“More Oregonians using end-of-life care instructions”
(Bend Bulletin — December 21, 2018)
More Oregonians are leaving instructions regarding their end-of-life wishes for medical interventions, but a growing percentage of those are choosing full resuscitation or other aggressive measures….
The Oregon forms will undergo some revisions next year, including a change in the name, from “physician orders” to “portable orders” to reflect the expanding range of providers who can now complete forms for their patients.

“California Tests Electronic Database For End-of-Life Wishes”
(Kaiser Health News — December 7, 2016)
A coalition of emergency and social service providers is working to create an electronic registry for POLST forms in California….
“California has been using them for nearly 20 years.  Filling out the forms is voluntary, but once they are completed and signed, they must be followed, and providers have immunity from criminal prosecution or civil liability when they do so in good faith.”
(Emphasis added.)

Medicare Plans to Pay Doctors for Counseling on End of Life”
(New York Times — July 8, 2015)
Medicare, the federal program that insures 55 million older and disabled Americans, announced plans on Wednesday to reimburse doctors for conversations with patients about whether and how they would want to be kept alive if they became too sick to speak for themselves.

“OHSU starts online system for end-of-life care instructions”
(Washington Times — June 16, 2015)
Oregon Health & Science University has launched a digital system for Physician Orders for Life-Sustaining Treatment, or POLST….The old system, which involved lots of scribbling, faxing and scanning of pink sheets of paper and then typing them into the registry, was prone to error.

“Physician Orders for Life-Sustaining Treatment Paradigm Has Pitfalls”
(ACEP Now — May 14, 2015)
POLST is a physician order.  However, it is often completed by nonmedical personnel and then signed by a physician and, in some states, by an advanced practice provider.  This process, combined with payer incentives, should raise one’s level of concern with the ability of the patient to fully understand the implications and provide informed consent.

“Study: Emergency providers often lack consensus on what patients intend when end-of-life forms come into play”
(AHC — May 4, 2015)
A new study suggests there is a lack of consensus or understanding about what patients intend when they fill out Physicians Orders for Life Sustaining Treatment (POLST) forms, and that this likely leads to patients either receiving or not receiving treatment contrary to their wishes….Researchers say that “do not resuscitate” orders are commonly misinterpreted to mean do not treat, and there are also practice and regional variations in how end-of-life care documents are interpreted.

“Study: Emergency providers often lack consensus on what patients intend when end-of-life forms come into play”
(AHC Media — May 4, 2015)
A new study suggests there is a lack of consensus or understanding about what patients intend when they fill out Physicians Orders for Life Sustaining Treatment (POLST) forms… Researchers say that “do not resuscitate” orders are commonly misinterpreted to mean do not treat, and there are also practice and regional variations in how end-of-life care documents are interpreted.

“Excela adopting end-of-life treatment guidelines”
(Pittsburgh Business Times — August 12, 2014)
Pennsylvania’s Excela Health is preparing to adopt POLST.  A half dozen long-term care facilities in Westmoreland County have already adopted the [POLST] guidelines and 60 counties have begun implementing them statewide.
Note:  Although the POLST form is widely used in Pennsylvania and the Dept. of Health has developed and distributes the POLST form, the state does not have a law or regulations governing the form.  It only has a law to study the form.

“Beware the rush to help people die”
(Los Angeles Times — July 2, 2014)
Physician orders written in advance can’t possibly cover every real-world eventuality.  Sometimes you have to render decisions on the spot, in response to new information such as an allergic reaction — or a change of heart….
Worse still, some POLST programs don’t even require a doctor’s input.

Illinois: “Expansion of end-of-life care order awaits governor’s signature”
(Chicago Tribune — June 16, 2014)
The bill would expand a medical order called POLST, for physician orders for life-sustaining treatment,that’s been available in Illinois for a little more than a year.
Illinois POLST law

“Connecticut enacts POLST law with revolutionary patient protections”
(POLST-views blogspot — May 18, 2014)
On May 9th, Connecticut enacted a law establishing a two-year pilot program for the POLST.  Special Act 14-5 requires that a patient or surrogate sign the MOLST form and that use of the form be voluntary.
Connecticut MOLST law

“End-of-life care proposal wins final passage”
(Connecticut Mirror — May 6, 2014)
The bill would allow the state Department of Public Health to create a pilot program for “medical orders for life-sustaining treatment,” or MOLST. The program would include training for health care providers on discussing options with patients, who could then document their choices in a form that would direct medical personnel on how to respond.

“Do patients understand what ‘DNR’ means?”
(POLST-views blogspot — May 5, 2014)
The very top box of the Physician Orders for Life Sustaining Treatment (POLST) addresses cardiopulmonary resuscitation.  The forms vary slightly from state to state but basically, there are two boxes: “attempt resuscitation” and “do not attempt resuscitation/DNR”. Do patients understand what it means to have a DNR box checked?  A recent study suggests that many do not.

“Emergency physicians ethics committee cautiously endorses POLST”
(POLST-views blogspot — April 28, 2014)
The ethics committee of the American College of Emergency Physicians (ACEP) has cautiously endorsed the POLST….There are some problems with the ACEP ethics committee article.  For one, the committee accepts uncritically the assertion of the National POLST Paradigm Task Force that physician liability concerns about the POLST can be waived away because “physicians are protected by common law by compliance with generally accepted standards of practice in their area.”  That’s simply not clear…..

“Catholic Health Association ethicist cautiously endorses POLST but calls for monitoring”
(POLST-views blogspot — April 14, 2014)
Ron Hamel, PhD is the senior ethicist for the Catholic Health Association of the United States….Dr. Hamel concludes by saying that “the jury is out…but premature to prohibit.” That’s an interesting conclusion, but probably the wrong one. When dealing with issues of life and death the precautionary principle should apply, and if the “jury is out” then facilities ought to wait before rushing to adopt the POLST.

“POLST’s Potential for Abuse”
(National Review Online — April 1, 2014)
With the growing technocracy in medicine, it becomes increasingly difficult for patients to have actual control over their own care.  Take the POLST, which stands for Physician’s Order for Life Sustaining Treatment.

“Illinois’ nutty POLST bill”
(POLST-views blogspot — March 31, 2014)
The bill describes who can have a POLST form:
“An individual of sound mind and having reached the age of majority or having obtained the status of an emancipated person to the Emancipation of Minors Act may execute a document (consistent with the Department of Public Health Uniform POLST form….) directing that resuscitation efforts not be implemented.”
That’s it. No suggestion that the individual be likely to die within a year.  No requirement that the individual have a serious illness or chronic frailty.

“Europe looks to LaCrosse for end-of-life model”
(La Crosse Tribune — March 20, 2014)
The Australian version, titled Respecting Patient Choices, recently received $15 million from the federal government to make it the national standard of care, Hammes said.  Wisconsin and Minnesota also have programs based on Respecting Choices– titled Honoring Choices — aiming to become statewide standards.
[Note:  Respecting Choices is a POLST paradigm program.]

“Task Force endorses Connecticut POLST bill containing expanded patient protections”
(POLST-views blogspot — March 17, 2014)
Having requirements for counseling and training written into law is important….In order to make sure that POLST implementation does not degenerate into a hurried process of completing a checklist with patients, its necessary to write safeguards into law.

“POLST Task Force repudiates extreme laws in New Jersey and Nevada”
(POLST-views blogspot — March 10, 2014)
Perhaps the most important new position announced by the National POLST Paradigm legislative guide is the explicit rejection of the liberal New Jersey and Nevada criteria for who should get a POLST….
One disappointment in the legislative guide is the Task Force’s continued refusal to say that a patient or surrogate signature on the POLST form should be mandatory.

“Rhode Island Medical Reporter Quotes Second Thoughts CT Concerns about MOLST”
(Not Dead Yet — January 23, 2014)
Some people with disabilities fear that MOLST laws, already in place in several states, could result in denial of life-saving treatment to those who want it.  Although MOLST is supposed to be voluntary, these activists say some nursing homes have presented it as mandatory.  And when emergency personnel see that pink sheet tacked to the wall, will they read all its details or will they assume it means “do not resuscitate?”

“Health Insight: New R.I. law aims to ease final days of terminally ill”
(Providence Journal — January 19, 2014)
Cathy Ludlum of Second Thoughts Connecticut says that “many people with severe disabilities feel personally threatened” by the law’s definition of “terminal illness” as “an incurable condition that, without the administration of life-sustaining procedures, will, in the opinion of the attending physician, result in death.”
“By definition,” Ludlum said, “we have incurable and irreversible conditions, and many of us use life-sustaining procedures every day of our (hopefully) long lives.”

“John Kelly Quoted in NPR Thanksgiving Day Article on POLST”
(Not Dead Yet — December 1, 2013)
Some members of the disability community have questioned whether POLST is being too broadly applied. Rather than giving people more control over end-of-life medical care, they say, it could mean interpreting “disabled” to mean “on death’s door.”
More on Disability Perspective

“After The Cranberries And Pie, Let’s Talk About Death”
(NPR — November 28, 2013)
“We would encourage doctors to reach out to patients if they would not be surprised if they died in the coming year,” Dr. Susan Tolle says, “or if they had advanced frailty. The little old lady hunched over their walker, that’s the definition of frailty.”
Tolle says, “People are handing out the form a little too early sometimes….”

Massachusetts: “John Kelly’s Response to IOM Online Survey or ‘We Love Our Tubes!'”
(Not Dead Yet — November 7, 2013)
Three months ago, my nurse brought me the Massachusetts MOLST form, with its preference for certain treatments in extremis.  She had been told that they were to complete these forms with every disabled person she follows.

West Virginia: “Are West Virginia’s doctors rejecting the POLST?”
(POLST views blog spot — October 28, 2013)
After a decade of promotion, and millions of public dollars spent by the Center on POST promotion, it is unlikely that doctors are unaware of the form.  Perhaps they just don’t like it.

Indiana: “Indiana’s POLST: Go hoosiers!”
(POLST views blog spot — October 21, 2013)
The Indiana POLST is called “POST” and it can only be offered to a “qualified person,” who is defined as someone who has an advanced progressive illness, advanced chronic frailty or a condition that will cause death in a short time.

Maryland: “New form directs doctors in life-threatening situations”
(Baltimore Sun — September 4, 2013)
Nursing homes and other health care facilities/programs are required to offer the Medical Order for Life Sustaining Treatment (MOLST) form to patients when they are admitted and to send it with the patient on transfer to another institution. The receiving institution is required to honor the form.
[Note: The MOLST form does not require the signature of the patient or the patient’s surrogate.}
Text of MD MOLST law
MOLST form

“Who is getting DNR orders on a POLST? More people than you think!”
(POLST views blog spot — August 7, 2013)
The National POLST Paradigm Task Force says that in order to determine whether a person should have a POLST, a clinician should ask, “Would I be surprised if this patient died in the next 12 months?”
[To access this article, see August listings in right column of page on the site]

“New form adds some teeth to end-of-life care preferences”
(USA Today — August 5, 2013)
Cathy Ludlum, one of Second Thoughts Connecticut’s leaders, said the POLST program may seem to increase patient options at first, but it actually limits those options by steering elderly people and people with disabilities toward death.

“Nevada’s new POLST statute: One more step down the slippery slope”
(Critical Analysis and Comment Blog — August 5, 2013)
The Nevada POLST is not limited to individuals who are near death. The NV law mandates that doctors offer a POLST to certain patients….”The subtle message that some will receive is that a ‘good’ patient should sign a POLST.”
Text of NV POLST law.

“A Novel Way to Document End-of-Life Preferences”
(New York Times — July 25, 2013)
To increase the number of patients who had documented their end-of-life preferences — including having a POLST that would be scanned into the patients’ medical records — a cash incentive was provided to medical residents.  If the residents recorded the information for at least 75 percent of discharged patients, they received a cash bonus.  Within months, 90 percent of patients’ preferences had been documented.

“In Response to Professor Thaddeus Pope’s article ‘Dangerous Catholic Attack on the POLST'”
(Bioethics.org — July 25, 2013)
Professor Pope asserts that “a number of scientifically rigorous studies have demonstrated POLST’s material benefits.” This is an exaggeration….[W]e are now seeing POLST statutes in New Jersey and Nevada that recommend the POLST for individuals with five years of life expectancy regardless of health.

White Paper
“The POLST paradigm and form: Facts and analysis”

(Linacre Quarterly — 2013)
An extensive analysis of POLST including its origins, legal status and implementation.

Not Dead Yet comments on POLST
(NDY press release — July 23, 2013)
Not Dead Yet provides video and written comments on POLST to the Institute of Medicine’s Committee on Approaching Death.
“‘How do we know the POLST medical order actually reflects the desires of the individual?’ [We worry] that, depending on how POLSTs are presented, they can make life-sustaining treatments — such as the use of feeding tubes — seem unbearable, even though many disabled people are able to live full lives because of them.”

“POLST — Need for Statutory Immunity”
(Medical Futility Blog — July 21, 2013)
Many question the need for statutory immunity for following the orders in a POLST. They argue that, through clinical consensus, clinicians can get the same thing by establishing POLST as the standard of care. But as debates in Washington state, this year, illustrated, this is often not perceived as sufficient.

“Dangerous Catholic Attack on POLST”
(Bioethics.net — July 19, 2013)
Most recently, the Catholic Medical Association, the largest association of Catholic individuals in health care, published a scathing attack on POLST.

“Not Dead Yet News & Commentary”
(Not Dead Yet — June 21, 2013)
Overview of disability rights spokesperson concerns about POLST

“POLST Authorizes Unilateral DNAR Orders”
(Medical Futility Blog — June 15, 2013)
In both Maryland and Vermont, a clinician can write a POLST order indicating “no CPR” even without patient or surrogate consent.

“New Form Helps Clarify End-of-Life Decisions for Patients and Families”
(NJ Spotlight — February 25, 2013)
The state is recommending that doctors and nurse practitioners complete this form with all patients who have a life expectancy of fewer than five years….When a POLST is completed, it travels with the patient and will ultimately be part of his or her electronic medical record as providers implement them. It has the force of a medical order, which means all healthcare providers are required to follow its instructions.
New Jersey POLST form

“Bill tackles loophole in law on end-of-life wishes”
(Seattle Times — February 24, 2013)
[L]ast summer, questions arose as to whether workers in those facilities were legally safe in following patients’ wishes as spelled out in the POLST form, said Joyce Stockwell, director of residential care services for the Department of Social and Health Services, in her letter warning adult-family-home providers their workers might not have legal protection.

Congressman Earl Blumenauer plans to reintroduce his controversial advance care planning legislation.  His earlier attempt, included in Obamacare, was deleted prior to final passage after being labeled as promotion of “death panels.”  Blumenauer is a supporter of Oregon’s assisted-suicide law and has been a featured keynote speaker for the assisted-suicide advocacy group, Compassion & Choices:
“Blumenauer turns again to end-of-life care, after mom’s death”
(Oregonian–February 16, 2013)
“In a bill Blumenauer plans to introduce by spring, Medicare and Medicaid would pay for voluntary consultations between doctors and patients about end-of-life wishes The bill would Provide grants to promote ‘physician orders for life-sustaining treatment’ [POLST]….”  Text of draft bill.

“The Deadly Failure of a Hospital to Follow a Patient’s Decisions About his Medical Care”
(Disability Rights California — February 2013)
Hospital neglected to provide medical interventions consistent with Mr. turner’s POLST when his physician revised his POLST form to say the opposite of the patient’s expressed wishes to receive life-sustaining treatment.

Medical Orders for Life-Sustaining Treatments (MOLST) Forms”
(Delaware Health and Social Services – Department of Health — November 14, 2012)
The State of Delaware division of Public Health, requests that all healthcare providers refrain from further use of the MOLST form.  There have been reports of facilities and healthcare providers completing “MOLST” forms on patients whose conditions do not meet the legal parameters for the form’s use in the state.

“POLST: An Emerging Model for End-of-Life Planning”
(The Elder Law Report — February 2009)
“With poor training, inadequate resources, and insufficient evaluation, the [POLST] process can regrettably morph into another systematic trampling of patient autonomy.”
[Quotation found on page 5]