meeting was held for education on the polst paradigm at the national hospice and palliative care organization conference in new orleans. 2008: polst becomes law in california and molst becomes law in new york. iowa pilot project conducted (continues until 2011). 2009: a second in-person formal meeting was held with the american academy of hospice and palliative medicine national conference in austin, texas. a major goal at this point was to have a structure similar in all states so it can be used and honored in all states and provide education about the program for efficient care. the program gives people the power to make the decision about their care and provides a guidance for decision-making about life-sustaining treatments. massachusetts molst demonstration project was implemented in massachusetts pursuant to a mandate in the commonwealth acts of 2008. ma molst form http://molst-ma.org/sites/molst-ma.org/files/molst%20form%20and%20instructions%208.10.13%20final.pdf oregon developed a was to allow electronic access of polst statewide to steer away from paper forms and accessing medical records. 2010: illinois forms the polst taskforce with support from more than 60 health care organizations; the catholic health association formally supports polst. 2011: polst is signed into law in new jersey after governor chris christie conditionally vetoes s-2197 for provisions allowing doctors to override people's wishes. vermont requires all out-of-hospital dnr/colst orders to be documented on the vermont dnr/colst form. 2012: first national polst conference held in san diego, california. iowa passes legislation to implement the current ipost form; illinois passes polst legislation (illinois introduces a polst form in march 2013). wisconsin catholic bishops warn against polst. anti-abortion groups react to wisconsin bishops' statement. anti-abortion leaders find parallels between polst ramifications and similar political expedients in history. the catholic health association specifies how the polst form is consistent with the catholic directives. 2013: polst becomes law in indiana and nevada; 20 states have polst statutes. 27 states was under development for this program. only 7 states at this point did not have polst in some form of development. 2015: california allows a nurse practitioner or physician assistant under a supervision of a physician to sign a polst form. 46 out of 50 states have the program established or under development. public opinions support supporters suggests that polst protects individuals’ right to make their own medical decisions and prevents the miscommunications among individuals, their family members and healthcare providers. most healthcare providers have a positive attitude towards polst, saying that the form presents peoples’ wishes and they can provide better care at individual's end of life with the form as guidance. this also prevents undesirable interventions as well as unnecessary expense on hospice care in healthcare facilities. for example, the medical teams would not give resuscitation or other medical interventions unless individuals indicate on the form. according to gundersen lutheran health system, after they have adopted polst, about $3000 to $6000 is reduced at the cost for each person because the hospital does not need to use medical devices or interventions to support their lives after they select “comfort measures” on the form. in addition, the formal document is a standard medical order signed by physicians and it is legal and effective in various healthcare settings and states. in other words, if individuals travel to another state with polst, hospitals in that state may accept the form as a plan of care and fulfill their wishes at the end of life. polst can be also an implement to examine any discrepancies between the actual treatments and individuals’ preferences, and to make sure that healthcare providers would respect and obey their preferences, which avoids the situations that may go against their wills. polst covers the limitations that advance directives and do not resuscitate or do not intubate orders (dnr/dni) have. for example, illnesses are unsteady as the conditions may change in severity every day. individuals that are 18 years old and above can fill out the form when they are healthy and competent, but they are not able to foresee what may happen and they may change their mind in treatments; however, advance directives does not take the changes into consideration. the form can be filled out by surrogates who may express individual’s preferences differently or mistakenly. also, dnr/dni only considers the situations that are related to cpr or intubation instead of recording individuals’ preferences in various situations at the end of their lives. some studies have shown that the providers were less likely to give aggressive treatments to individuals with dnr/dni even if they are not critically ill. a study on nursing home residents has found that most residents with dnr order marked on polst forms that they would like to have treatments, which indicates that dnr orders do not convey individual’s ideas and polst is a better tool in communication. therefore, advance directives and dnr/dni may not be truly proposed to improve individuals care at the end of life. opposition conservative groups like the media research center and the catholic medical association argue that there will be unintended consequences or potential abuses fostered by polst adoption. in some cases, this results from the way the enabling laws are written. any document determining an individual's quality of care or life-ending choices carries moral and ethical dilemmas, and polst instruments (or the protocols and circumstances through which they are explained to people) have been criticized for this by the catholic medical association. the catholic health association answered criticisms in a white paper entitled “the polst paradigm and form: facts and analysis.” polst is viewed to be conflicted with catholic ideas on “rightful and wrongful refusal decisions” especially on the last section about nutrition and antibiotics, and the catholic providers feel being forced to follow the order since it seems to violate their beliefs. healthcare providers also mention some challenges that have met when introducing polst to individual's and their families. they may not feel comfortable discussing the content of the form or they have trouble understanding it. people and their family members may also have different opinions when completing the form. in addition, the physicians may not support polst and refuse to sign because they are worried that they may need to take the blame or have some responsibilities by signing it even if using the form is a part of standard care. some people suggested that some of the questions on polst forms do not apply to actual situations. for example, in the first section on the form is asking if individuals would like to have resuscitation when they do not have pulses. but some individuals may not be hospitalized or they may be living at home and cannot get access to the interventions mentioned on the form; and thus, the question is not suitable for their situations. some people also doubt whether polst truly delivers individuals’ wills as they may change their minds in different contexts. studies have shown that up to 45% of individuals were unsure of their choices when they first filled out the form and up to 70% of individuals had inconsistent answers when the questions were phrased differently. polst research several studies have supported the use of polst as a tool to ensure people's wishes are complied with: in a 1998 study, charts of 180 residents at eight oregon nursing facilities were evaluated over a one-year period. where the polst forms of residents included "do not resuscitate" and "comfort measures only" orders, none of the residents received unwanted cardiopulmonary resuscitation (cpr), intensive care, or ventilator support. in 2000, a study was done in the community setting showed that cpr use was 91% consistent with the use of polst forms and about 45% of medical interventions were consistent with section b of the form. in 2004, a survey of selected sites revealed that the polst program was widely used in oregon nursing facilities. care matched polst instructions to a high degree regarding cpr (91%), antibiotics (86%), intravenous fluids (84%), and feeding tubes (94%). level-of-care instructions (from comfort care to full medical intervention) were followed less often (46%). a 2004 survey of 572 emts in oregon found that a large majority of emts felt that the polst form provides clear instructions about people's preferences and is useful when deciding which treatments to provide. in 2009, researchers assessed the penetration of polst in hospice programs in oregon, wisconsin, and west virginia. a pilot study indicated that polst was used widely in hospices in oregon (100%) and west virginia (85%) but only regionally in wisconsin (6%). a majority of hospice staff believed polst was useful in preventing unwanted resuscitation and initiating conversations about treatment preferences. in 2010, an observational retrospective cohort study compared the use of the polst forms with the use of "traditional" orders in 1711 residents of nursing facility. the results of the study showed that individuals are much more likely to include end-of-life treatment preferences "beyond cpr status" when using the polst form (98%) than "traditional practices or orders" (16%). in 2011, a survey with a sample size of 169 was done in the state of new york found that the about half of the providers and healthcare workers including physicians, nurses, social workers and nurse practitioners felt the need to have a conversation about the polst form with the individual they are providing service to. the major reason for this preference is these healthcare workers believe the use of the polst form can lead to better management of disease symptoms such as pain. in 2014, state death records containing cause and location of death were matched with polst orders for people (sample size n = 58,000) with a polst form in the state registry. conclusion: the association with numbers of deaths in the hospital suggests that end-of-life preferences of people who wish to avoid hospitalization as documented in polst orders are honored. in 2014, a chart review study with a sample size of 31,294 studied polst forms in an electronic registry in the state of oregon. the study found that polst forms came in six different combinations: "dnr/comfort measures only, dnr/limited interventions, dnr/full treatment, attempt cpr/comfort measures only, attempt cpr/limited interventions, and attempt cpr/full treatment." the data showed that about 10% of the order combinations appeared confusing and did not make sense to providers because they seemed contradicting. the most popular combinations were "dnr/comfort measures and dnr/limited interventions." in 2016, the study included comparison of two different state polst programs having distinct demographics and different approaches to electronic registries. a key metric evaluated was the relationship of polst medical intervention orders to in-hospital death, which was evaluated using polst data linked with state death records. conclusion: the study indicated similar patterns between the two states in which comfort only orders less often resulted in in-hospital deaths, compared to full treatment orders. limitations of polst research most of the studies done on the polst research were done in oregon where there is a less diverse demographic. the studies done on polst were mainly done in nursing facilities. therefore, there is limited data about polst in other parts of the community. in addition, the training for the physicians for implementing polst program may not be consistent throughout different healthcare facilities.