By Laura Herman, Dementia and Eldercare Professional
Many people don’t want CPR. It’s often ineffective and carries the risk of significant injury. It also increases the chance of dying in a chaotic hospital setting. Emergency personnel are required to administer CPR, unless they have a physician’s order that authorizes them to refrain. This is where advance care planning and the POLST come in.
Advance Care Planning and POLSTs
Advance care planning is the process of considering what types of future healthcare situations you may encounter, and how you’d like to be treated should those situations arise.
For example, if you were to be the victim of a terrible car accident, and the doctors agreed that they could keep your body alive with ventilators and nutritional tube feeding, would you want them to do that? What if there was a 10% chance you would someday regain consciousness? What about a 50% chance? These situations are never clear cut, but having the tough conversations, and documenting your preferences in accordance with your state laws, will increase the chance that your wishes will be met and that your family won’t have to struggle with them on their own without your input or guidance.
A POLST is one type of advance care planning document. It specifically addresses your wishes for whether or not you’d like CPR along with other potentially invasive and uncomfortable treatments, such as a breathing machine, tube feeding, and intensive care.
Are you struggling to talk about these tough issues with your loved one? Learn how to start conversations around hospice care here
What is a POLST, MOLST, or MOST?
POLSTs don’t exist in every state, and they go by different names in the states where they do. For simplicity, they’re called POLSTs when referring to them generally.
- California - POLST - Physician Orders for Life-Sustaining Treatment
- Connecticut - MOLST - Medical Orders for Life-Sustaining Treatment
- Kentucky - MOST - Medical Orders for Scope of Treatment
- Missouri - TPOPP - Transportable Physician Orders for Patient Preferences
View your state’s participation in the program – and preferred name for this form – at the National POLST website.
POLSTs are medical orders
Just like a prescription for medication, a POLST is a medical order. A doctor (or another authorized provider) must sign it for it to be valid.
POLSTs take the place of DNR orders (usually)
Some states utilize DNR (Do Not Resuscitate) Orders. They’re sometimes called DNAR (Do Not Attempt Resuscitation) or AND (Allow Natural Death) orders. In most states, if you have a POLST you don’t need a separate DNR, because the POLST covers resuscitation. Talk to your doctor about exactly what you need in your situation.
POLSTs don’t replace living wills
Every adult should have a living will to communicate preferences regarding treatment in the event of incapacitation. Living wills are often combined with healthcare power of attorney documents, which authorize someone to make medical decisions.
A POLST is appropriate for individuals who are very ill or frail, generally in the last year or so of life. Emergency medical providers can withhold CPR based on a POLST, but not a living will.
Need more information about living wills and the advance care planning process? Learn more here.
What Makes Up a POLST?
There are four sections in most POLST forms.
Cardiopulmonary Resuscitation (CPR)
You can choose to allow CPR, including chest compressions and machine-assisted interventions like defibrillation (shocking the heart) or intubation (inserting a tube into the lungs).
Goals of Care and Medical Treatments
Specify one of the three goals of care.
- Full Treatment - (required if you want CPR) The goal of full treatment is to keep you alive by any medically appropriate means necessary, which may include surgery, intubation, or intensive care.
- Selective Treatment - Restore your ability to function, but avoid intensive care and resuscitation. IV fluids, antibiotics, and other treatments may be administered. You may be transported to the hospital.
- Comfort Care - Manage discomfort and allow natural death. Transport to hospital only if necessary for comfort.
What is Comfort Care? Learn more about Comfort Care here.
Medically Assisted Nutrition (Tube Feeding)
You can allow tube feeding permanently, temporarily, or not at all.
Your doctor can write special instructions about treatments not covered elsewhere in the POLST, like transfusions, dialysis, or pacemakers.
Who Needs to Know About POLSTs?
Your healthcare proxy, healthcare team and loved ones should be aware of your POLST. Emergency responders will need immediate access to it, so keep it somewhere visible and easily available, such as the refrigerator or medicine cabinet. Some areas have POLST Registries that keep a copy on file for easy reference.
POLSTs Help Avoid Unnecessary Medical Trauma
POLSTs fulfill an important part of advanced care planning for people who are terminally ill, frail, or wish to forgo aggressive medical treatment in favor of comfort. POLSTs go by different names throughout the nation, and they aren’t available in all states.
Emergency responders can withhold CPR based on a POLST, but it must be signed by an authorized healthcare professional. Talk to your doctor if you’d like to complete one.
Are you interested in hospice but not sure you’re ready? Consider the differences between hospice and comfort care here.
- Zanders, R., Druwé, P., Van Den Noortgate, N. et al. “The outcome of in- and out-hospital cardiopulmonary arrest in the older population: a scoping review.” European Geriatric Medicine, 08 March 2021, link.springer.com/article/10.1007/s41999-021-00454-y.
- Huntingdon, George. “CPR rarely works – why do people have so much faith in it?” The Guardian, 04 June 2018, www.theguardian.com/healthcare-network/views-from-the-nhs-frontline/2018/jun/04/cpr-misconception-death-doctors.
- “Advance Care Planning.” National POLST, polst.org/advance-care-plans/.
- “National POLST Maps.” National POLST, polst.org/programs-in-your-state/.