Understanding a Polst

In addition to an advance directive and a durable power of attorney for health care, people who are living with a serious or terminal illness or who are very elderly and/or medically frail may choose to work with their healthcare provider to create a document known as POLST. An acronym for Physician’s Order for Life-Sustaining Treatment, POLST refers to a legally binding set of medical orders that spells out a person’s wishes regarding specific measures that might be used to artificially sustain life. The document is designed to improve patient care by providing a clear means of communicating end-of-life wishes to first responders and emergency medical personnel. It does not replace an advance healthcare directive and/or durable power of attorney for health care.

Unlike a living will or advance healthcare directive, which is a legal document intended to give direction to a healthcare surrogate, a POLST is a medical order written and signed by a qualified healthcare provider. State laws differ, but in most cases this may be a physician, an advanced practice nurse or a physician assistant. Emergency personnel and hospital staff are obligated to follow the instructions a POLST contains. However, in the absence of a POLST (or an out-of-hospital DNR), they are required to initiate resuscitation efforts when they are called to respond to an emergency. Similarly, hospital staff will generally continue high-intensity treatment until they locate the patient’s healthcare proxy or next of kin. 

When a healthcare provider signs a POLST, the order goes into effect immediately. It is also portable, so if the patient is transferred from one hospital to another, or from a hospital into a long-term care facility, the order will still be valid and doesn’t need to be written again. Patients who are living in the community should keep their POLST form in a highly visible place, such as taped to the refrigerator or the bedroom door or above the bed. Most POLST forms are brightly colored (in California they are pink) so they can easily be seen by emergency personnel. 

Although the specifics of each state’s POLST forms may vary somewhat, POLST generally addresses the following issues around life-sustaining care:

• Cardiopulmonary resuscitation (CPR)
  • Full treatment (requires the full-treatment medical interventions below)
  • No CPR
• Medical interventions
  • Full treatment: comfort care plus intubation, mechanical ventilation and cardioversion (electric shocks to restart the heart or convert abnormal heart rhythms)
  • Selective treatment: comfort care plus antibiotics, oxygen and intermittent positive pressure breathing, but no intubation or intensive care
  • Comfort-focused care: pain relief and manual assistance in breathing (for example, suctioning or positioning and oxygen)
• Artificial hydration and nutrition (including feeding tubes)
  • Short-term, long-term or none at all

According to National POLST, nearly all states have adopted the national POLST paradigm as of 2025,  but the specifics of the programs may vary from state to state. The acronyms used to describe the form may be different as well. According to the National POLST Paradigm, terms currently in use include:

• POLST (Physician Order for Life-Sustaining Treatment)
• POST (Physician Order for Scope of Treatment)
• MOLST (Medical Order for Life-Sustaining Treatment)
• MOST (Medical Order for Scope of Treatment)
• TPOPP (Transportable Physician Order for Patient Preferences)
• COLST (Clinician Order for Life-Sustaining Treatment)
• DMOST (Delaware Medical Order for Scope of Treatment)
• IPOST (Iowa Physician Order for Scope of Treatment)
• TOPP (Transportable Order for Patient Preferences)
• AzPOLST (Arizona Provider Order for Life-Sustaining Treatment)
• LaPOST (Louisiana Physician Order for Scope of Treatment)
• OkPOLST (Oklahoma Physician Order for Life-Sustaining Treatment)
• PAPOLST (Pennsylvania Order for Life-Sustaining Treatment)
• WyoPOLST (Wyoming Providers Order for Life-Sustaining Treatment)
• SAPO (State-Authorized Portable Order)
• SMOST (Summary of Physician Order for Scope of Treatment)

To learn the exact specifications for POLSTs in your state, visit this interactive map on POLST.org.

Sources

“Intermittent positive pressure breathing”. Physiopedia. https://www.physio-pedia.com/Intermittent_positive_pressure_breathing 

“National POLST Map.” National POLST. https://polst.org/programs-in-your-state/ 

As of this writing, there is no consistent policy across the U.S. regarding how to address a conflict between a person’s advance directive and POLST. In some states, the most recent document executed by the patient takes precedence, while in others the healthcare proxy designated in the advance directive can rescind or override a more recent POLST. Further, in most jurisdictions, a healthcare surrogate can request that a provider sign a POLST for a patient who is incapacitated or unable to make their wishes known. In theory, this document could contradict the patient’s advance directive if it were not available at the time. 

With that being said, most states attempt to preserve the right of the patient to make autonomous decisions and give precedence to the person’s wishes when those wishes are known. As in the case of the doctrine of “first person consent” for organ and tissue donation, the patient’s wishes are paramount and should not be overridden by the next of kin. Therefore, most providers will make every effort to determine what the patient would want. 

For example, if the patient’s advance directive clearly states “No CPR,” but the health care proxy wants “everything done,” it’s unlikely that the patient’s wishes would be ignored. On the other hand, if the person’s advance directive indicates they want doctors to do everything possible to save their life, a health care proxy might successfully override that wish with a POLST if the patient’s condition were to drastically change (for example, if a previously healthy 75-year-old person had a devastating stroke). 

This murky legal terrain highlights the importance of ongoing communication between the patient and surrogate decision-makers, including the health care proxy and next of kin. This is especially true for patients who are considering a POLST, for whom goals of care frequently change. 

Sources

“First Person Consent: OPOS across the country are adapting to the change”. United Network for Organ Sharing. https://unos.org/wp-content/uploads/unos/registires_combined.pdf