PolstEdit

Polst, commonly written as POLST, refers to a practical framework of physician orders for life-sustaining treatment. It is the portable, patient-centered set of orders that translates a person’s preferences into concrete medical actions across care settings—whether in a hospital, a clinic, an ambulance, or at home. Rather than relying on vague documents, Polst seeks to align what clinicians do with what a patient truly wants when communication may be difficult or impossible. The tool sits at the intersection of individual choice, medical judgment, and real-world care delivery, and it has become a standard feature of many health systems in the United States and beyond. In practice, Polst is intended to complement broader planning tools such as advance directives and durable power of attorney for health care, while functioning as a physician-ordered guide for those moments when patient wishes must be enacted in care settings.

The form is designed to be portable: it travels with the patient through emergency medical services and across settings from acute hospitals to long-term care facilities and private residences. Unlike traditional advance directives, which outline goals of care in general terms, a Polst specifies actionable orders about resuscitation, admission to intensive care, and the use of artificial life-sustaining interventions. By translating preferences into orders, it reduces the ambiguity that can arise when a patient cannot speak for themselves. It is important to emphasize that a Polst does not replace patient autonomy or the role of surrogate decision-makers; rather, it records decisions that a patient or their legally authorized representative has already made with a clinician’s input.

Origins and purpose

Polst originated in a health-care environment that recognized the gap between broad advance directives and the urgent, life-and-death decisions made in emergencies. The program began in the early 1990s in several states and evolved into a national framework known as the POLST Paradigm. Proponents argue that Polst gives patients real influence over the care they receive in the most critical moments, when time is short and misunderstandings can lead to treatments that are misaligned with goals of care. The guiding idea is to respect patient preferences while ensuring medical teams have clear, actionable orders to follow. In this sense Polst functions as a bridge between patient autonomy and clinical decision-making, helping to avoid both unintended over-treatment and unanticipated under-treatment.

Process and scope

A Polst is typically prepared after a discussion between the patient (or their surrogate) and a clinician—often a physician, nurse practitioner, or physician assistant—who helps translate values and goals into concrete medical orders. The form commonly addresses several domains:

  • Resuscitation status, including whether to initiate or withhold CPR in cardiac arrest.
  • The level of medical interventions to be pursued in the event of serious illness, such as the use of ventilators or intensive care.
  • Comfort-focused measures and symptom management, prioritizing pain relief and quality of life.
  • Specific instructions about artificial nutrition and hydration, if applicable.
  • Any other patient-specific preferences that should guide care during crises.

The orders are signed by a clinician and become binding in the same way as other medical orders. They are intended to be updated if the patient’s health status or preferences change. Because Polst forms travel with the patient, they are meant to provide continuity of care across settings, including hospice care and inpatient units, and to reduce the likelihood of care that contradicts the patient’s stated goals.

From a practical standpoint, Polst is designed to support shared decision making in urgent situations. It is not a substitute for((durable power of attorney for health care|power of attorney)) or for ongoing conversations about goals of care, nor does it eliminate the need for ongoing re-evaluation as circumstances evolve. In many systems, Polst is used alongside, but distinct from, broader end-of-life care planning, helping ensure that the patient’s preferences remain the guiding force when medical decisions must be made rapidly.

Controversies and debates

Polst has generated a range of discussions, reflecting the broader tension between autonomy, resource considerations, and clinical judgment. On one side, proponents emphasize that Polst empowers patients to exert control over their medical trajectories and to avoid non-beneficial or burdensome interventions. They argue that when clinicians and patients engage in candid conversations about goals of care, the resulting orders tend to align treatment with the patient’s values, leading to greater satisfaction and, in some cases, reduced use of aggressive, life-prolonging treatments that may not improve quality of life.

Critics raise concerns about capacity, comprehension, and the risk of coercion, especially among vulnerable patients or those with limited health literacy. Some worry that the urgency of emergency settings could lead to rushed discussions or misinterpretation of the orders by frontline staff. Others point to variability across states and institutions in how Polst forms are implemented, interpreted, and enforced, which can create confusion for patients who move between care settings. There are also debates about whether Polst might, in some cases, contribute to rationing of care or to the perception that decisions about life-sustaining treatments are primarily driven by cost considerations rather than patient values. Proponents counter that the consent process, physician oversight, and regular re-evaluation are essential safeguards that minimize these risks and keep patient welfare at the center.

From a pragmatic standpoint, the fiercest critiques sometimes frame Polst as a potential instrument of “death-panel” style policy. In response, advocates note that Polst documents reflect autonomous choices made by patients or their authorized surrogates, with explicit professional guidance, and that the orders remain reversible. They stress that Polst is most effective when implemented with clear education, proper capacity assessment, and robust medical ethics oversight. The dialogue around Polst therefore centers on ensuring access to clear information, safeguarding against coercion, and maintaining high standards for documentation and training.

Evidence, outcomes, and policy implications

Empirical studies of Polst show varying outcomes depending on the health system, population, and implementation. In many settings, there is greater concordance between the care patients receive and the preferences documented in Polst forms, particularly regarding avoidable aggressive interventions near the end of life. Some analyses indicate reductions in unwanted hospital or ICU stays, while others emphasize the importance of supporting patient autonomy and ensuring that the forms are used as intended rather than as a blanket tool for cost-saving. The debates often align with broader policy questions about how to harmonize patient choice, clinical judgment, and system-level incentives. See end-of-life care and palliative care for related conversations about how care goals are translated into practice across settings.

Implementation challenges frequently include disparities in access to knowledgeable clinicians who can guide conversations, differences in state laws and standardization of forms, and the need for ongoing education within hospitals and long-term-care facilities. Advocates argue that standardizing training, coupling Polst with robust advance care planning, and ensuring that surrogates understand the patient’s goals will strengthen the integrity of the process. Critics contend that without careful safeguards, the form could be misused or misapplied, underscoring the necessity of professional oversight and patient-centered education.

See also