POLST and Advance Directives
By Dr. Kenneth Rothaus, MD
The New York Times (Tuesday March 17, 2015 page D2) recounted the story of an elderly man who had an advance directive that stated in the case of a critical medical problem he wanted to be comfortable only, and did not wanted any heroic measures. Unfortunately, several years later he developed dementia and ended up in a nursing home. While at the home he unfortunately developed a critical medical problem that necessitated transfer to a hospital. The patient underwent 3 surgical procedures, another hospital transfer, and ended up with a tracheostomy and a stomach tube. After all this occurred, his advance directive was discovered.
The patient did recover enough to return to the nursing home. At the present time, however, in addition to the original advanced directive, he is covered by a POLST form. POLST stands for Physicians Orders for Life Sustaining Treatment. This patient’s POLST form states comfort care only and, therefore, another episode such as above should not happen to him.
Advance Directives are legal documents that enable a patient to make decisions about end of life care before they are too ill to do so. A living will lets you spell out which medical treatments you would accept or reject (e.g., dialysis, respirator, etc.), your decision to refuse care and your desire to donate organs.
You can also use another document (durable power of attorney for health care) to appoint someone as your proxy to make health care decisions for you if you are incapacitated. (Make sure it is someone you trust!)
A POLST form on the other hand is a medical order. It indicates the patient’s wishes. Medical personnel are required to follow these orders. POLST forms are filled out by a physician in consultation with the patient. Because they are medical orders, however, they must be signed by the doctor and not the patient. The POLST forms stay with the patient wherever they go and should be clearly visible so that first responders or emergency medical personnel can find them easily.
A discussion of the differences and similarities between POLST forms and Advance Directives can be found on the POLST website. They are summarized in the following table:
| POLST | ADVANCE DIRECTIVE |
| For critically ill patients regardless of age | For anyone age 18 and up |
| Medical Orders for Current Treatment | Instructions for future medical care |
| Guides actions by MDs, RNs and EMTs in an emergency | Appoints a Health Care Proxy but does not guide MDs, RNs and EMTs in an emergency |
| Guides inpatient decisions when available | Guides inpatient decisions when available |
The article in the Times ended by saying these documents are not enough, but that frank discussions with friends and family are necessary. Your caregivers will rely on these individuals, especially in those circumstances where the advance directives and POLST forms are not available.
When are you going to have this discussion with your family?
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