Physician Orders For Life Sustaining TreatmentEdit
Physician Orders for Life Sustaining Treatment (POLST) are standardized medical orders that translate a patient’s preferences about severe illness or frailty into actionable instructions for healthcare professionals across care settings. POLST programs exist in many jurisdictions and are designed to travel with a patient—from the home to the emergency department to the hospital or hospice—so clinicians can honor the patient’s choices even when the patient cannot speak for themselves. They complement, rather than replace, traditional documents like advance directives, and they are typically completed after a detailed discussion among the patient, a surrogate decision-maker if one exists, and a clinician who can translate values into concrete medical orders. In practice, POLST emphasizes patient autonomy and clarity of intent, while aiming to reduce nonbeneficial, burdensome, or discordant interventions that patients do not want.
Definition and scope
POLST is a medical orders framework, not a standalone legal will or a broad statement of preferences. It is designed for individuals with serious illness, advanced frailty, or a high likelihood of deteriorating health where decisions about life-sustaining treatments may need to be made in urgent or changing circumstances. A POLST form typically documents concrete choices about interventions such as cardiovascular resuscitation, intubation and mechanical ventilation, artificial nutrition, and the level of comfort-focused care. In many programs, the form also includes preferences about antibiotics and various levels of treatment intensity, all expressed as orders that emergency personnel and hospital staff must follow.
In this sense, POLST is closely tied to day-to-day clinical decision-making and the realities of acute care. It is distinct from a broad, long-term advance directive that outlines broad goals and appoints a surrogate; instead, POLST translates those goals into short-term, actionable medical orders. See, for example, DNR (Do Not Resuscitate) discussions and related emergency medical services workflows, which are often integrated into POLST processes.
How it works
A POLST discussion typically occurs between a clinician and the patient (or a legally empowered surrogate) when there is a reasonable expectation that the patient could lose decision-making capacity in the near future. The clinician helps the patient understand the likely outcomes of different interventions and how those outcomes align with the patient’s values and goals. The result is a form with concrete orders, such as:
- Do Not Resuscitate (DNR) or full resuscitation with specific limitations
- Limits on mechanical ventilation or admission to intensive care
- Preferences regarding artificial nutrition or hydration
- A stated preference for comfort-focused care or a combination of comfort with limited life-prolonging treatments
Because POLST is a set of medical orders, it must be signed by a clinician. The patient or surrogate signature indicates consent and preference, which helps ensure the orders reflect the patient’s values rather than a clinician’s default approach. The form is designed to be portable; it should be readable and readily available in the patient’s chart, on laminated cards, or within electronic health records to facilitate immediate recognition by EMS personnel and hospital staff. See portable medical orders and electronic health record for related concepts.
Variants and jurisdictional differences
Different states or countries may label and structure POLST programs somewhat differently. Some places use the exact term POLST, while others call it Medical Orders for Life-Sustaining Treatment or a similar variation. The core idea, however, remains the same: provide clear, short-term medical orders that reflect patient preferences across care settings. Jurisdictional differences can involve who can sign, what treatments are listed, how often orders must be updated, and how the forms are stored and transmitted across care settings. See Medical Orders for Life-Sustaining Treatment for a closely related framework used in many regions and state law for how these orders interact with local statutes.
Portability, interoperability, and safeguards
Effective POLST programs emphasize portability: orders should be honored wherever care is delivered, whether in a home, clinic, ambulance, or hospital. This requires reliable communication channels, standardized forms, and integration with electronic health record systems or health information exchanges. Safeguards include ensuring patients have capacity to participate meaningfully in the conversation, that surrogates have the legal authority to speak on behalf of patients when needed, and that there are regular opportunities to revisit and revise the orders as health status or values change. Clinician education, clear language, and culturally sensitive communication help reduce misinterpretation and ensure that the orders truly reflect patient preferences.
Controversies and debates
POLST sits at an intersection of patient autonomy, clinical judgment, and resource stewardship, and it invites robust debate across the political spectrum.
Autonomy versus professional guidance: Proponents argue POLST respects patient autonomy by translating values into actionable orders rather than leaving critical decisions to chance in emergencies. Critics worry about potential pressure from clinicians or families, or about situations in which patient wishes could be inadvertently overridden by a default to life-sustaining care. Advocates respond that POLST is a collaborative, clearly documented process requiring consent and ongoing discussion, not a one-off form.
Rationing concerns: Some critics worry that POLST could function as a tool for rationing care, particularly if cost considerations or systemic incentives influence decisions. Proponents counter that POLST is about aligning care with patient goals and evidence of benefit, not about price tags; they emphasize that appropriate limits on interventions can reflect patient values and improve the quality of remaining life.
Vulnerable populations and bias: Skeptics raise concerns about whether certain groups—due to age, disability, or health literacy—may feel pressured to agree to less aggressive treatment. Supporters highlight informed consent, the involvement of trusted surrogates, and the necessity of clear communication to mitigate bias. They emphasize that well-structured POLST programs include safeguards to ensure decisions are patient-centered and voluntary.
Conscience protections: A recurring policy question is whether clinicians should have the right to refuse participation in certain orders on moral or religious grounds. The conservative perspective often defends conscience protections while preserving patient access to care by enabling timely handoffs to willing providers, and by clarifying that POLST is about honoring patient preferences rather than compelling clinicians to provide unwanted treatments.
Impact on downstream care: Critics note that POLST discussions can be emotionally charged and may influence care trajectories in ways that affect hospital utilization, hospice enrollment, and family dynamics. Proponents stress that transparent conversations about goals of care help avoid aggressive treatments that do not improve quality of life and instead prolong suffering, while enabling care that aligns with the patient’s values.
Implementation, policies, and practical considerations
Successful POLST programs tend to share several practical features:
Early and ongoing conversations: Rather than a one-time form, POLST is part of an ongoing dialogue about goals of care, with updates as health status or preferences evolve. This aligns with informed-consent principles and patient autonomy.
Clear, understandable language: Forms should use plain language to minimize misinterpretation, with options that are specific enough to be actionable in a crisis.
Clinician training and supports: Physicians, nurses, and other clinicians gain confidence through training in communication, ethics, and the legal framework surrounding POLST.
Family and surrogate involvement: When patients cannot speak for themselves, surrogates play a critical role, guided by the patient’s known values and prior statements.
Alignment with other instruments:POLST works alongside advance directives, surrogate decision-maker designations, and do-not-resuscitate orders in a coordinated care plan. See also end-of-life care for broader context.