physician orders for life-sustaining treatment physician orders for life-sustaining treatment polst (physician orders for life-sustaining treatment) is an approach to improving end-of-life care in the united states, encouraging providers to speak with the severely ill and create specific medical orders to be honored by health care workers during a medical crisis. polst began in oregon in 1991 and currently exists in 46 states; some of the 46 states have the program in development. the polst document is a standardized, portable, brightly colored single page medical order that documents a conversation between a provider and an individual with a serious illness or frailty towards the end of life. a polst form allows emergency medical services to provide treatment that the individual prefers before possibly transporting to an emergency facility. the polst form is a medical order which means that the polst form is always signed by a medical professional and, depending upon the state, the person stated on the form can sign as well. a pragmatic rule for initiating a polst can be if the clinician would not be surprised if the individual were to die within one year. one difference between a polst form and an advance directive is that the polst form is designed to be actionable throughout an entire community. it is immediately recognizable and can be used by doctors and first responders (including paramedics, fire departments, police, emergency rooms, hospitals and nursing homes). comparing to documents like dni (do not intubate), dnr (do not resuscitate) and advance directive, the polst form provides more information on the types of end-of-life treatment or intervention that the severely ill wishes to receive. organizations that have passed formal resolutions in support of polst include the american bar association and the society for post-acute and long-term care medicine (amda). other organizations that support polst include the american nurses association (ana); the institute of medicine; national association of social workers (nasw); aarp; the american academy of hospice and palliative medicine (aahpm); pew charitable trusts; and the catholic health association of the united states (cha). polst orders are also known by other names in some states: medical orders for life-sustaining treatment (molst), medical orders on scope of treatment (most), physician's orders on scope of treatment (post) or transportable physician orders for patient preferences (tpopp). what is polst? polst represents a significant paradigm change in advance care policy by standardizing provider communications through a plan of care in a portable way, rather than focusing solely on standardizing individuals' communications via advance directives. the polst paradigm requires people, their surrogates, and their providers to accomplish three core tasks: first, polst begins with a conversation between a health care professional and the individual (or the individual's authorized surrogate) about treatment options in light of the individual's current condition. second, the individual's preferences for treatments are incorporated into medical orders, which are recorded on a highly visible, standardized form that is kept at the front of the medical record or with the individual if they lives in the community. polst forms record several treatment decisions common to seriously ill individuals, for example: cardiopulmonary resuscitation; the level of medical intervention desired in the event of an emergency (comfort only, limited treatment, or full treatment); and the use of artificial nutrition and hydration. as technology and treatment options change, polst forms will also continue to evolve. third, providers encourage that the polst form travels with the individual whenever he or she moves from one setting to another, thereby promoting the continuity of care throughout a community. the polst form is designed to transfer across treatment settings, so it is readily available to medical personal, including emts, emergency physicians and nursing staff. the polst program relies upon teamwork and coordinated systems to ensure preferences are honored throughout the health care system. research suggests the polst form accurately represents individual's treatment preferences the majority of the time and that the treatments provided at the end of life match the orders on the form. an established polst program can help reduce unwanted hospitalizations and honor the person's end-of-life wishes. to determine whether a polst form should be completed, clinicians should ask themselves, "would i be surprised if this person died in the next year?" if the answer is that the patient's prognosis is one year or less, then a polst form is appropriate. in a 2006 consensus report, the national quality form observed that "compared with other advance directive programs, polst more accurately conveys end-of-life preferences and yields higher adherence by medical professionals." the national quality forum and other experts have recommended nationwide implementation of the polst paradigm implementation of polst was also recently recommended by the national academy of sciences institute of medicine in its report, "dying in america: improving quality and honoring individual preferences near the end of life." the report was released september 17, 2014. what is on the polst form? the polst form is usually on brightly colored paper that contains options for the individual depending on their health status. the polst form generally has sections for the individual to decide whether or not they would want cardiopulmonary resuscitation (cpr), the preferred level of medical interventions, or whether they would want artificially administered nutrition. depending on the state, there could be another section on whether to provide antibiotics or not to the individual being treated. cardiopulmonary resuscitation (cpr) the first section in most forms across the country is section a indicating the option between performing cardiopulmonary resuscitation (cpr) or no cpr or do not attempt to resuscitate. the national form indicates mechanical ventilators, defibrillation and cardioversion under the cpr specifications. a study showed that there was a high rate of providers respecting the individual's decisions regarding cpr, which means that the providers respected their wishes according to the polst forms. preferred medical interventions the level of medical intervention is on section b on the polst form with options of "comfort measures", "limited additional treatment", or "full treatment". this section only comes into play if the individual still has a pulse and/or if they are still breathing. the "comfort measures" allow for natural death and only helps the individual relieve any pain. by checking this box, the individual also prefers to not be transferred within the hospital. the "limited additional treatment" includes the comfort measures in addition to basic medical treatment. “full treatment” authorizes the medical team to try their best to save the individual and increases their life expectancy with all methods. this option also allows people to choose whether they would like a trial period. a study on nursing home residents has shown the high rate that the medical teams respected peoples’ wishes and gave the treatments according to the orders on section b. artificially administered nutrition this section comes with options of “no artificial nutrition by tube”, “defined trial period of artificial nutrition by tube” and “long-term artificial nutrition by tube”. if the person is able to chew and swallow, the food will be taken by mouth. studies have found that orders to withhold artificial nutrition such as feeding tubes are usually executed by the providers. antibiotics for most versions of polst, orders on antibiotics have three aspects: antibiotic use to enhance comfort, the use of intravenous/intramuscular (iv/im) antibiotics, and the use of antibiotics at time of disease or infection. studies have found orders on the use of antibiotics for comfort measures tend to have high rates of execution. however, one study has shown that providers do not always obey the individual's wish to not use antibiotics. because certain types of infection have other means to alleviate symptoms of infections, so physicians' use of antibiotics seem to be generally unaffected by polst. how is the form used? before executing the orders on the polst form, the provider should talk with individuals with decision-making capacity to obtain the most updated wishes. this process or conversation could involve families and relevant care providers as well to ensure people are well-informed while making the decisions. if the individual has made changes to the polst form, the provider is responsible for explaining how the updates will likely impact future treatment plans. however, if the individual is not able to make decisions because of his or her disease state, the clinicians have to follow orders on preexisting polst forms. differences between an advance directive and a polst form advance directive an advance directive is a legal document that allows individuals to share their wishes with their health care team during a future medical emergency. the document does so by designating a guardian that the user wants their medical team to work with (also known as a “surrogate”). competent individuals above 18 years of age can fill out an advance directive. an advance directive allows an individual to state what treatments he or she would want in a medical crisis, but it is not a medical order. advance directives are not portable in a sense that it is not accessible across medical systems, so it is the individual's responsibility to have the form on them at all times. this can bring up challenges as it can be difficult to locate and may need to be interpreted when it is needed. because advanced directives are filled out by healthy individuals, the form is considered to be a "living will". polst form unlike advance directives, a polst should only be used when the individual is at the end of life. typically, if a provider believes that a person's condition will increasingly worsen and make it hard for the individual to survive another year, then a polst form is used. a polst form turns a person's treatment wishes outlined in an advance directive into medical orders. the polst form provides explicit guidance to healthcare professionals under predictable future circumstances based on the individual's current medical condition. the polst form is reviewed more frequently compared to an advance directive to make sure that the form complies with the individual's wishes in treatments as the disease progresses. compared to the advanced directive, there is no designated surrogate when using a polst form. to designate a health care surrogate, people must use an advance directive. once a surrogate is established and if the individual does not have the mental capacity to make decisions, the surrogate has the authority to make decisions on the polst form; the amount of authority for the surrogate, however, varies per state. an individual does not need to have an advance directive to have a polst form although health care professionals recommend that all competent adults have advance directives in place; this will help healthcare providers shape a more concise medical decision that better reflects the individual's wishes. lastly, the polst form is very portable unlike the advance directive. it is the physicians' responsibility to make it accessible across different medical facilities. polst history 1991: oregon polst task force was created. the first prototype was known as the medical treatment cover sheet (mtc). this was created to have a standard to regulate medical orders for people with chronic illnesses. the list of treatments that were included on this form would include resuscitation, nutrition, intubation, antibiotics, and other preferred medical interventions. focus groups and studies were executed to evaluate the use of this form and significant modifications were made. this later resulted in the renaming of the form. 1993: the name "physician orders for life-sustaining treatment or polst was adopted. 1995: first polst form was used in oregon. many other states wanted to implement this in their own settings so there was a need for execution at a national level. 2004: national polst paradigm task forced was developed. the task force included oregon, new york, pennsylvania, washington, west virginia, and wisconsin. the focus of the task force was to create an organized standard and help other states who wanted to develop a polst program. georgia, idaho, maryland, nevada, utah, and vermont were all under development for polst by this time. 2005: the national task force created a more clear description and outline of the program including the contents of the form and developments of endorsement for the program. this was established as the national polst paradigm. 2006: west virginia and wisconsin adopt polst. iowa forms a focus group of health care providers to address the current fragmentation of end-of-life communication. 2007: a formal in-person