When is a POLST appropriate compared with an advance directive?

An advance directive records a person's care preferences and can be part of advance care planning for any competent adult. A POLST is intended for people with serious advanced illness whose current health status calls for portable medical orders. It turns treatment preferences into orders for care teams to use across settings.

An advance directive records preferences for future care

Advance care planning is the process of discussing future care in case a person loses the ability to make decisions. Patricia Bomba told the U.S. Senate Special Committee on Aging that this planning is appropriate for all adults 18 and older, including people without life-limiting illness. Amy Vandenbroucke likewise said all competent adults should have an advance directive, regardless of health status.

The conversation and the document serve different roles. Joan Teno described advance care planning as ongoing communication between a patient and a health care provider. Its first aim is to clarify the patient's goals and values, often leading to a written advance directive. CaringInfo describes an advance directive as the record of a planning process based on a person's values, beliefs, preferences and medical issues.

A POLST is for serious advanced illness

Vandenbroucke said POLST is for patients with serious advanced illness when their current health status indicates a need for standing medical orders for emergency or future care. She described it as a set of medical orders for a specific population, not an advance directive. For a healthy person, she identified an advance directive as the appropriate tool.

This distinction is about what the document does and when it is used. An advance directive records preferences for future care. A POLST translates goals of care into orders that can guide treatment. Discussing advance care planning does not, by itself, mean a person needs a POLST. A clinician can discuss whether someone's illness and current care needs make POLST appropriate.

Orders can travel across care settings

Amy Vandenbroucke described POLST as a way to make a patient's goals of care available as portable medical orders across care settings. Karl Steinberg similarly described POLST as helping translate treatment preference discussions into actionable orders. The document is designed to help care teams find and use those orders when treatment decisions arise.

That portability depends on the form being available and reflecting the person's preferences. A California Senate Judiciary Committee analysis quoted the Coalition for Compassionate Care of California's report of provider knowledge gaps and operational misalignments involving POLST, prehospital DNR orders and advance directives. The analysis points to a practical reason for careful coordination when these documents are used together.

Review the POLST as preferences change

A person's health and preferences can change. Findings reported in JAMA Network Open support POLST as a way to translate end-of-life values and preferences into medical orders, and stress frequent review so the form reflects current preferences. In a separate discussion, Sean Morrison said a well-completed POLST in the right setting can help care, while one completed poorly or in the wrong setting can lead to care that conflicts with a person's goals, including withholding appropriate care.

For physicians and practice owners, a concrete step is to make review part of the POLST process and confirm that the orders match the patient's current preferences. The form should follow a conversation about goals and values, with the patient's decision-making capacity assessed. Researchers reporting repeat POLST interviews also said advance care planning ideally takes place within an established patient-clinician relationship.

"While all competent adults- regardless of health status- should have an advance directive, not everyone should have a POLST. As discussed in Section (1) above, POLST is for a very specific patient population. The POLST form is a set of medical orders, similar to the do-not resuscitate (allow natural death) order. POLST is not an advance directive."

Amy Vandenbroucke, Senate Special Committee on Aging June 26, 2013 Hearing Written Testimony by Amy Vandenbroucke, Executive Director National POLST Paradigm Program

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