National Standards and State Variation in Physician Orders for Life-Sustaining Treatment Forms

Abstract

Background:

The Physician Orders for Life-Sustaining Treatment (POLST) Paradigm is used across the country to document the treatment preferences of seriously ill or frail patients as medical orders. The National POLST Paradigm Task Force maintains consensus-based standards for POLST programs and uses these to determine whether a state POLST program is developing, endorsed, or mature.

Objectives:

To evaluate state program form adherence to national standards.

Design:

Document review.

Measurements:

Forms from endorsed/mature (n = 21) and developing (n = 23) states were compared with national standards to assess adherence to required and optional form elements.

Results:

Required elements were present on 84% of endorsed/mature state POLST forms and 73% of the developing state POLST forms. Compliance with required elements in endorsed states ranged from 50% to 100%. Three endorsed/mature states (14%) had forms that met all of the required elements fully and 14 (67%) had forms that met the all of the elements fully or partially.

Conclusions:

There is variability in adherence to required and optional standards as well as challenges in interpreting and applying existing standards. Although there may be legal and logistical barriers to the existence of a national POLST form, standardization remains an important goal to support patient-centered care.

Introduction

The Physician Orders for Life-Sustaining Treatment (POLST) Paradigm is an advance care planning program used to elicit, document, and honor the treatment preferences of patients with advanced serious illness or frailty in the form of portable, actionable medical orders. It is intended for patients whose medical provider would not be surprised if they died within a year. Restricting the focus to this patient population makes it possible to provide patients with tailored information about their diagnosis, prognosis, and treatment options as well as the likely outcomes of available interventions, so POLST orders can be both values-based and informed. These decisions are documented on POLST forms that include active orders addressing the use of cardiopulmonary resuscitation (CPR), medical interventions, including hospitalization, antibiotics, and artificial nutrition. Use of the POLST form is associated with patients receiving care that is consistent with documented preferences.¹

The POLST Paradigm was originally developed in Oregon in the early 1990s to help ensure that patient preferences to have or to decline specific treatments were known and honored. Its use spread and programs built on the Oregon POLST model are now in development or in use in a majority of states within the United States.² A growing demand for consultation resulted in a formal meeting of leaders from POLST-using states in 2004 to share resources and strategies. This group became known as the National POLST Paradigm Task Force (NPPTF). Initially, members were representatives from states with active programs and select advisors. The NPPTF is now comprised of one representative from each state with an endorsed program along with advisors who have expertise in the law, emergency medical services, long-term care, and technology. POLST Paradigm form and program standards were developed by the NPPTF through expert consensus, and a review process was created to identify whether states met the established standards. In 2014, the Institute of Medicine encouraged states to “develop and implement a [POLST] paradigm program in accordance with nationally standardized core elements” to improve quality and honor individual preferences near the end of life.³

State POLST programs are classified by the NPPTF as developing, endorsed, mature, or nonconforming.² Developing programs are at various stages of implementation ranging from an initial design of a program to implementation of a statewide program. To be deemed developing, states must submit an application to the National POLST Paradigm outlining program information and meet with the Developing States Assistance Committee (DSAC). State programs approved as developing are asked to provide regular updates to the national office and must meet with the DSAC at least once every two years to maintain their “developing” designation. The 23 developing states as of August 2017 were: Alaska, Alabama, Arizona, Connecticut, Delaware, Florida, Illinois, Kentucky, Michigan, Minnesota, Mississippi, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, North Dakota, Ohio, Oklahoma, Rhode Island, South Carolina, Texas, and Wyoming.

Endorsed programs must submit an application that includes a checklist outlining required and optional form elements as well as specific information about the program operations. This includes information about quality improvement activities, supporting laws and regulations, educational materials, and evidence that the state's program is working on sustainability.² The 21 endorsed programs as of August 2017 were: California, Colorado, Georgia, Hawaii, Idaho, Indiana, Iowa, Kansas/Missouri (joint program), Louisiana, Maine, Montana, New York, North Carolina, Oregon, Pennsylvania, Tennessee, Utah, Virginia, Washington, West Virginia, and Wisconsin.

The California, Oregon, and West Virginia programs are further classified as Mature. Mature status is the highest level of endorsement by the NPPTF and is reserved solely for states with statewide POLST programs, where it is the standard practice to introduce the POLST Paradigm to persons with serious advanced illness or frailty whose medical provider would not be surprised if they died within the year. This designation also reflects statewide use by 50% or more of hospitals, nursing homes, and hospices in objectively defined regions of the state (e.g., hospital referral regions)⁴ as well as ongoing quality assurance activities.²

Nonconforming programs have elements that are determined to be inconsistent with the overall goals of the National POLST Paradigm. These are states with forms that significantly deviate from national form standards. The common problem is that these forms deconstruct the three medical intervention options and/or provide a menu of treatment options to choose; this likely increases inconsistent order sets or confusion among emergency medical professionals on what treatment to provide. Nonconforming states as of August 2017 were: Massachusetts, Maryland, and Vermont. (Note: Massachusetts is working on revisions to their program to meet NPPTF recommendations).

There are multiple benefits of maintaining shared standards for both state POLST programs and forms. Standardization increases the portability of POLST forms and helps increase the likelihood that patient preferences will be honored, irrespective of where the patient is geographically during a medical emergency. Ideally, a patient from Oregon would be able to vacation in Arizona with confidence that her POLST form will be recognized and honored by the Arizona Emergency Medical Services. Since POLST forms are portable medical orders, the more similar all-state forms can be to one another, the more support the entire POLST Paradigm provides to individual patients.

Additionally, shared standards help ensure consistency and create a national standard for the POLST Paradigm concept, which supports education and advocacy for the National POLST Paradigm at the federal level. It also facilitates the sharing of information, policies, and educational resources to support an effort that is primarily grassroots and minimally funded.⁵ Finally, standardization helps ensure that research findings are generalizable outside the state in which the study was conducted.

A review of state POLST forms was conducted to determine adherence and variation from NPPTF POLST form standards.

Methods

Setting

This study was conducted at Indiana University. The Indiana University Institutional Review Board (IRB) determined that the study did not require IRB review. The study includes current state forms available as of August 30, 2017.

Protocol

Forms based on the POLST Paradigm were identified from online resources, including www.polst.org and state-specific program websites. When the form was not readily available online, forms were requested from state program representatives. At the time of the review, the National POLST Paradigm Office identified 23 developing POLST Programs, 18 endorsed (not mature) POLST Programs, and 3 mature POLST Programs. An additional three programs were identified by the NNPTF as not conforming to NNPTF standards.

Protocol for reviewing forms

In the first round of review, 10 forms were selected representing a subset of developing, endorsed, and mature states. Forms were reviewed independently by the authors (SEH, RC) and a consultant from the NNPTF using the NPPTF required optional form standards. For each element, the forms were categorized based on whether they met the stated standard (yes or no). Ratings were combined in one spreadsheet and were reviewed to identify rating discrepancies between the three reviewers. Discrepancies were discussed until consensus was achieved about the appropriate rating. This process included clarification from the consultant about how each item was interpreted by the NPPTF. A log was kept to track decisions resulting from these discussions. Forms were rereviewed to ensure consistent application of the consensus definition across states. The remaining 37 forms were reviewed by SEH and RC using the same process to identify and resolve any discrepancies in ratings.

Required and optional form elements

The NPPTF website includes a guidance document for states seeking endorsement a status and status application form that includes information about form specifications.² Required and optional form elements were abstracted from this guidance document verbatim and used to develop operational definitions for use in the analysis (see Appendix Table A1). A secure, online survey tool was developed to facilitate ratings of each form. Forms were rated as to whether they met each element fully or whether they met the element only partially.

Endorsed/mature state POLST form characteristics

Forms from endorsed/mature states were reviewed to assess specific form characteristics, including naming conventions, the sequence of medical interventions orders (e.g., whether the first order was for the lowest level of treatment or the highest), the inclusion of antibiotics, the placement of intravenous (IV) fluids/artificial hydration, and the inclusion of space to identify goals of care.

Results

Forty-seven forms were reviewed for adherence with required and optional POLST form elements. The form from one developing state (Alabama) was unavailable for review. Nonconforming states were removed from the analysis because these forms are specifically identified as failing to meet NPPTF program and/or form standards.

Adherence to required and optional form element standards

On average, endorsed/mature state forms contained 84% of all required elements and developing state forms contained 73% of all required elements. Required elements present on all forms include language indicating the form is a physician or medical order (100%) and CPR instructions (100%). Language next to the signature and date sections clearly indicating that both required elements were present on just 33% of forms (see Table 1).

Table 1.

Percent of Required POLST form Elements Present on State POLST Forms by Endorsement Status

Required elements	Endorsed state forms (n = 21)	Developing state forms (n = 22)	Total
1. Medical order, %	100	100	100
2. Patient information, %	81	68	74
3. Not advance directive; no witness, %	90	73	81
4. Signature and date, %	43	23	33
5. Discussed with patient or surrogate, %	95	100	98
6. CPR instructions, %	100	100	100
7. Level of medical intervention, %	95	82	88
7A. Comfort measures, %	90	73	81
7B. Limited additional interventions, %	62	36	49
7C. Full interventions, %	90	77	84
8. Additional orders, %	62	73	67
9. Food and fluids, %	81	50	65
10. Comfort always provided, %	100	82	91
11. Prohibited language, %	95	86	91
Overall, %	84	73	79

CPR, cardiopulmonary resuscitation; POLST: Physician Orders for Life-Sustaining Treatment.

On average, endorsed state forms included 75% of optional elements and developing states included 71% of optional elements. Consistent with optional form standards, most forms did not include language suggesting the form would be rescinded during surgery (93%) and a majority were uniquely identifiable (93%). About two-thirds (70%) require a patient or surrogate signature, an optional form element that is highly recommended by the NPPTF. However, only 23% had a space for the time of the healthcare professional signature (see Table 2).

Table 2.

Percent of Recommended POLST Form Elements Present of State POLST Forms by Endorsement Status

Recommended elements	Endorsed state forms (n = 21)	Developing state forms (n = 22)	Total
12. Uniquely identifiable form, %	100	86	93
13. Name of state, %	90	91	91
14. Positive language, %	100	86	93
15. Copied version of form is valid, %	81	86	84
16. Form is not rescinded during surgery, %	90	95	93
17. All medical orders on first page, %	86	73	79
18. HIPAA language, %	81	100	91
19. Patient's signature, %	67	73	70
20. Additional form information, %	52	18	35
21. Form instructions, %	57	50	53
22. Time of signature, %	24	23	23
Overall, %	75	71	73

HIPAA, Health Insurance Portability and Accountability Act.

Endorsed states' adherence with required form element standards

Table 3 contains specific information about the presence or absence of required POLST form elements for endorsed/mature states. Three states (Colorado, Oregon, and Washington) had forms that met all of the required elements (range = 50–100%) and 14 states (67%) met all of the required elements partially or fully (range = 83–100%).

Table 3.

Presence of POLST Form Elements Fully or Partially Meeting Requirements on Endorsed State POLST Forms

		Form elements
State	Year endorsed (mature)	E1	E2	E3	E4	E5	E6	E7	E7A	E7B	E7C	E8	E9	E10	E11	Fully met (%)	Fully and/or partially met (%)
Colorado	2011	•	•	•	•	•	•	•	•	•	•	•	•	•	•	14 (100)	14 (100)
Oregon	2004 (2013)	•	•	•	•	•	•	•	•	•	•	•	•	•	•	14 (100)	14 (100)
Washington	2005	•	•	•	•	•	•	•	•	•	•	•	•	•	•	14 (100)	14 (100)
Indiana	2017	•	•	•	•	•	•	•	•	•	•	≈	•	•	•	13 (93)	14 (100)
Virginia	2016	•	•	•	•	•	•	•	•	•	•	≈	•	•	•	13 (93)	14 (100)
Kansas & Missouri	2016	•	•	•	•	•	•	•	•	•	•	•	≈	•	•	13 (93)	14 (100)
Wisconsin	2008	•	•	•	•	•	•	•	•	≈	≈	•	•	•	•	12 (86)	14 (100)
Iowa	2015	•	•	•	≈	•	•	•	•	≈	•	•	•	•	•	12 (86)	14 (100)
Louisiana	2012	•	x	•	≈	•	•	•	•	•	•	•	•	•	•	12 (86)	13 (93)
Maine	2015	•	•	•	≈	•	•	•	•	≈	•	•	•	•	•	12 (86)	14 (100)
Montana	2011	•	•	•	≈	•	•	•	•	•	•	≈	•	•	•	12 (86)	14 (100)
North Carolina	2008	•	x	•	•	•	•	•	•	•	•	≈	•	•	•	12 (86)	13 (93)
Pennsylvania	2011	•	x	•	≈	•	•	•	•	•	•	•	•	•	•	12 (86)	13 (93)
Tennessee	2009	•	•	•	≈	•	•	•	•	•	•	≈	•	•	•	12 (86)	14 (100)
California	2009 (2016)	•	•	•	≈	•	•	•	•	≈	•	•	•	•	•	12 (86)	14 (100)
West Virginia	2005 (2013)	•	•	•	≈	•	•	•	•	≈	•	•	•	•	•	12 (86)	14 (100)
Hawaii	2009	•	•	≈	≈	•	•	•	•	•	•	•	≈	•	•	11 (79)	14 (100)
Utah	2011	•	•	•	≈	•	•	•	•	≈	•	≈	x	•	•	10 (71)	13 (93)
Idaho	2011	•	•	•	≈	•	•	•	•	≈	•	x	≈	•	•	10 (71)	13 (93)
Georgia	2013	•	x	•	x	x	•	•	≈	•	•	•	•	•	x	9 (64)	10 (71)
New York	2006	•	•	x	•	•	•	≈	≈	≈	≈	≈	•	•	•	7 (50)	12 (86)

• = element present and requirement fully met; ≈ = element present and requirement partially met; x = element not present and/or requirement not met.

E1 = Element 1 (Medical Order); E2 = patient identifying information; E3 = not an advance directive; no witness; E4 = form requires healthcare professional signature and date; E5 = space to note discussed with patient or surrogate; E6 = CPR instructions; E7 = level of medical intervention; E7A = comfort measures; E7B = limited additional interventions; E7C = full interventions; E8 = additional orders; E9 = offer food and fluids; E10 = comfort always provided; E11 = prohibited language. Forms were counted as meeting the required element if the form element was fully met. See Appendix Table A1 for further information.

Endorsed/mature state POLST form characteristics

The most common naming convention included the acronym POLST or a highly similar variation (45%), followed closely by the Physician Orders for Scope of Treatment (POST) or a highly similar variation (35%), Medical Orders for Scope of Treatment (MOST: 10%), Medical Orders for Life-Sustaining Treatment (MOLST: 5%), and Transportable Physician Orders for Patient Preferences (TPPOP: 5%). The sequence of the orders in Medical Interventions (typically section B of the form) varied, with a majority of states placing comfort measures at the top of the list followed by limited additional interventions and full treatment (67%). About a third of forms (35%) include a separate section for antibiotics, whereas 45% of forms mentioned it as part of the medical interventions. The remainder (20%) include no mention of the use of antibiotics either as a separate section or in the medical intervention orders. A minority of forms (15%) included a space to write in personal treatment goals on the form. IV fluids were most often mentioned in the orders about medical interventions (60%), although an additional 25% of forms included references both in the medical interventions section and elsewhere. The remainder (15%) mentions IV fluids in the section on artificial nutrition. A majority (81%) permitted nurse practitioners/advance practice nurses to sign in addition to physicians.

Discussion

The required and optional POLST form elements reflect consensus regarding best practices as determined by leaders from states with endorsed programs. A review of state POLST forms suggests there is variation in form composition and adherence to NPPTF standards among both endorsed and developing states. Among endorsed states, full adherence with NPPTF required form elements ranged from 50% to 100%, although every endorsed state form met all requirements at least partially. This suggests that while the endorsement process is largely an effective strategy at ensuring standardization, the guidance may require some re-evaluation or modification.

The observed variability in adherence with required elements likely reflects, in part, the evolution of form standards over time. Standards are reviewed and revised periodically to reflect new thinking and innovation. However, forms that were previously approved are not re-evaluated against the new system, but are instead “grandfathered” in, maintaining their endorsed status. In some states, modifications to the form are constrained by legislative or regulatory considerations, making even periodic form updates complex and time intensive.

In addition to the effort involved in making form modifications through legislation, changes require educational activities and updates to materials to explain the new changes. There are also expenses associated with printing a new version of the form and the potential for confusion about whether the old version is still valid. It is particularly challenging to make updates in states where the form itself is embedded in the state statute authorizing use; therefore, the NPPTF strongly recommends against having the form or specific form language in legislation.⁶

Form variation is driven in part by differences among state legislation and regulation.^5–7 For example, state law controls scope of practice and medical order signature authority, which leads to variation in who may sign POLST forms. There is a similar level of variation in other advance care planning tools, such as living wills or healthcare power of attorney appointments,⁸ so this is not unique to the POLST Paradigm model. Moreover, state POLST legislation is shaped by existing laws pertaining to out-of-hospital do-not-resuscitate order statutory and regulatory provisions, advance directive and default surrogate statutes, and statutes about who is authorized to forgo life-sustaining treatments.^5,7 The development of state forms is often a political process that requires collaboration between clinicians, government representatives, and community stakeholders. Modifications or changes to form language may not be easy to make depending on who has authority over form content (e.g., the legislature, a state agency, or a community coalition) and the processes required to enact change. It would take significant effort and political will to modify existing state legislation and regulations to meet a uniform national standard, although it is possible this could happen over time. A recently awarded grant to the NPPTF will facilitate the development of a national form that states could choose to adopt as an alternative. The NPPTF also supports efforts to pass federal legislation to promote standardization and education such as the Patient Choices and Quality Care Act of 2017 introduced by a bipartisan group of representatives on June 7, 2017.

The variability in adherence to required elements may also reflect different opinions about the value of various sections. A majority of existing research has focused on the orders addressing medical interventions,¹ but data about the value of specific individual elements are unavailable for most of the required elements. For example, there are no data available about what kinds of orders are documented in the required space for “additional orders,” whether these represent orders or preference clarifications, and how this information is used in practice. There are also no data suggesting there is an association between feeding tube orders and feeding tube use.⁹ Orders for a time-limited trial of a feeding tube are frequently disregarded.¹⁰

In contrast, data suggesting that the use of antibiotics is not associated with antibiotic orders⁹ led some states to drop a separate antibiotics section, despite evidence indicating antibiotic use was largely consistent with preferences.¹⁰ Language referencing antibiotics was incorporated into medical intervention orders on some state forms, but is completely absent on other state forms. Variation has also been observed in the use of the phrase “Allow Natural Death,” possibly reflecting a lack of consensus about the meaning of when this phrase is appropriate.¹¹ It is unclear whether any of these form variations are problematic or negatively impact the use of the tool to support patient-centered care within a specific state as the evidence regarding the inclusion or exclusion of specific elements is limited. However, the variation does make it harder to achieve the goal of standardization.

Limitations

Assessing adherence with optional and required form element standards was challenging. Several of the elements included subjective standards that were difficult to interpret, which may complicate state efforts to create forms that meet national standards. Additional information about the standards typically brought to bear by the National POLST Paradigm Office was helpful but not always obvious, reflecting the value of state consultation with the DSAC. It was particularly difficult when elements contained multiple standards, as the grouping of standards was not always intuitive and was sometimes so complex that it was unclear which components were viewed as most important. It was unclear when subelements were preferred versus mandatory, although the number of states with partially compliant forms suggests some components are more important than others. There was also overlap in several of the required elements, such as the elements related to medical intervention orders. The guidance documents provided minimal information about the rationale for elements noted as mandatory versus optional.

Data analysis was initially performed by three people who worked collaboratively to develop shared operational definitions. Many of the form elements are subjective and challenging to both interpret and apply, so it is possible others will interpret these elements differently. The inclusion of a member of the National POLST Paradigm Office in the initial analysis process helped increase the likelihood that the elements were interpreted in a manner consistent with the standards applied in practice. Another limitation is that this study did not include an analysis of program guidelines or relevant state laws. The program criteria may include important contextual factors for how the program works in any given state. Some states, for example, may clearly note that the signature of the physician or treating clinician is required in program guidelines or state law, even if language noting the signature and date are required is absent from the form. Others, like New York, do not explicitly require a signature, but one is necessary to complete the form electronically. A review of these laws was outside the scope of this review. Finally, the review reflects forms available as of August 30, 2017. Any revised forms released after this date are not included in the analysis.

Recommendations

Based on this review of POLST forms, it is recommended that the POLST form required and optional elements be reviewed and updated to clarify expectations and to make standards even more concrete and objective. Additionally, it is also recommended that forms from endorsed and mature states be periodically reviewed by both the NPPTF and endorsed states to ensure that these continue to adhere to the national standards.

The National POLST Paradigm Office is developing a review process for endorsed states with attention to achieving a balance between supporting innovation and acknowledging the political realities in some states. Future research could include the development of a broad-based consensus about which elements are essential versus optional among a wide range of stakeholders. This approach could potentially increase innovation by including alternate perspectives in the form development process. Finally, findings suggest that despite the use of common terminology, there are important differences in state forms and likely important differences in state laws when present. Clinicians, policy makers, and researchers should be attentive to the differences between states when providing clinical care, making policy, or practice recommendations, and drawing conclusions about the generalizability of research conducted with specific state forms.

Conclusion

State POLST forms are largely adherent with nationally established standards. However, sometimes documents that are identified as POLST paradigm programs diverge significantly from these standards, making it debatable as to whether they truly are POLST forms or something else. It is unclear whether these variations are positive or negative and there is no data about the clinical impact of these differences. However there are numerous clear benefits to the promulgation and maintenance of national standards. POLST form standards should be periodically reviewed and evaluated to ensure they are clear and consistently applied to both developing and endorsed/mature states programs. Standardization across states remains an important goal to support patient-centered care through the use of the National POLST Paradigm.

Footnotes

Acknowledgment

The authors are grateful to Amy Vandenbroucke, Executive Director of the National POLST Paradigm, for her consultation on this project.

Rebecca Critser is grateful for the support of the Richard and Kaye Woltman Endowed Fellowship in Health Communication and the Rancho Santa Fe Fund.

Author Disclosure Statement

Susan Hickman is the Chair of the National POLST Paradigm Task Force Research and Quality Assurance Committee and the Associate Director of the Indiana Patient Preferences Coalition.

Appendix Table A1.

National Physician Orders for Life-Sustaining Treatment Paradigm Form Element Standards

Element	Description of standard	Operational definition
1	The form clearly states that it is a “medical order.” (Medical Order)	Form is described as a medical order, clinician order, physician order, or provider order.
2	Patient identifying information is on all pages of the form. (Patient Identifying Information)	Form includes a space for patient identifying information on every page that records patient information.
3	The form is clearly not an advance directive nor combined with an advance directive, such as a living will, healthcare power of attorney, or other such document, and should not require any witnesses or notarizations of patient signatures. Form shall not be combined with organ donation authorization. Note: A POLST form may document the existence of these other documents, but cannot be combined with them. (Not an Advance Directive; No Witness)	Form does not include a section to appoint a healthcare representative or surrogate decision maker, although information identifying this person was accepted. Form can document that the patient has made a decision about organ donation or has an advance directive. Witnesses acceptable only in the case of verbal consent to orders on the form or when an optional component.
4	The form requires a valid healthcare professional signature or electronic authentication (pursuant to state laws and regulations) and date of signature. Note: It is a regulatory standard that all medical orders indicate the date issued. The date will allow identification of the most current order. (Signature and Date)	Form indicates that both the signature of the healthcare professional and date are required, preferably by noting separately that each is “mandatory.” Forms partially meet this requirement if this language is missing from either the signature or date sections.
5	The form indicates with whom the order was discussed, the patient (if he/she has decision-making capacity) or the patient's surrogate (as identified by state law). Unless there is restrictive language in the state's law, the surrogate has the authority to complete an original and/or revise a POLST form for a patient lacking decision-making capacity. (Discussed with Patient or Surrogate)	Form must include a designated field for indicating with whom the orders were discussed (e.g., a list of checkbox options). Additionally, the form could not limit the surrogate's ability to complete or revise a POLST form when the patient lacked decision-making capacity.
6	The form provides explicit direction about resuscitation (CPR) instructions or patient preferences if the patient is pulseless and apneic. (CPR Instructions)	Form includes clear directions about full code vs. do not resuscitate.
7	In addition to orders, with regard to CPR, the form indicates the level of medical intervention for the patient (exact wording for each level may vary from state to state) comfort measures; limited additional interventions; or full interventions. Each level of intervention shall contain a description of the services to be provided and the site in which they will be provided (see 7A–C). (Level of Medical Intervention)	Form includes three levels of treatment and each level is accompanied by a description of included and excluded treatments. Site information must also be provided. Forms were considered partially compliant if there were multiple separate medical orders about medical interventions.
7A	“Comfort Measures”: Cleary provides option for “comfort measures” as the focus of treatment. Must provide instructions indicating that the patient is to be transferred if comfort needs cannot be met in the patient's current setting. (Goal is to include language affirming a patient's right to be transferred to receive comfort care.) (Comfort Measures)	Form includes a comfort measure option and explicit instructions to transfer only when necessary for comfort without contradictory instructions or statements. Partially compliant forms separated decisions about hospitalization from comfort measures order or did not explicitly mention comfort care as a reason to transfer.
7B	“Limited Additional Interventions”: Clearly provides a separate option for “limited additional interventions.” This option includes measures for comfort as well as hospital admission and treatment with IV fluids, antibiotics, and cardiac monitoring as appropriate. This option does not include intubation, advanced airway interventions, or mechanical ventilation. It may include less invasive airway support (e.g., CPAP, BiPAP) depending on patient's preferences. Should include a statement “Avoid intensive care” or “Generally avoid intensive care.” (Limited Additional Interventions)	Separate option for limited interventions was met if element 7 was met; exact language was not necessary. Form must address: (a) explicit instructions for comfort care or inclusion of comfort-focused care when receiving limited interventions by reference to the comfort care level of treatment; (b) orders for hospital admission, that is, instructions for when to transfer the patient; (c) treatment with IV fluids; (d) treatment with antibiotics (unless the form included a separate antibiotics section); and (e) treatment with cardiac monitoring. Additionally, a form was considered fully compliant if cardiac monitoring was omitted as long as all other criteria were satisfied; (f) the statement “avoid intensive care,” “generally avoids intensive care,” or comparable statement was satisfied by any reference to avoiding, but not prohibiting, intensive care. Partially compliant forms contained a majority but not all of the elements listed.
7C	“Full Interventions”: The form clearly provides an option for “full interventions.” Option includes treatments, such as intubation and mechanical ventilation in an intensive care unit. Patients who are already receiving long-term mechanical ventilation may indicate treatment limitations in the “Other Orders” space in the level of medical intervention section. (Full Interventions)	Forms criteria include: (a) separate option for full interventions; (b) treatment with intubation; (c) treatment with mechanical ventilation; and (d) treatment in an intensive care unit. (See Element 8 for “Other Orders.”) Partially complaint forms contained a majority but not all of the elements listed.
8	In section with orders for level of medical intervention, form must provide space for “Additional Orders.” (Additional Orders)	Form must include a section within the level of intervention section for “additional orders” or “other orders.” Sections titled “additional instructions” or “other instructions” were considered partially compliant. Forms with space for additional orders or notes elsewhere on the form were considered partially compliant.
9	Form clearly states that food and fluids must be offered if feasible, regardless of the level of care chosen. (Food and Fluids)	Form must include a statement applying to both food and/or fluids indicating they must be provided or should be offered if feasible. “Clearly” was defined as on the front of the form in the same section as the orders. States with language about offering food and/or fluids in the form instructions and forms that used the term “desired” were considered partially compliant because it was unclear whether this was the patient's desires or the desires of a proxy decision maker.
10	Form clearly states that comfort measures are always provided, regardless of the level of treatment chosen. Note: Preference is for “level of treatment” rather than “level of care” to avoid confusion. Care should always be provided, whereas treatment may be withheld based on patient's preferences. (Comfort Always Provided)	Met by either explicitly stating that comfort measures are always provided in the directions or instructions or by including the comfort care level of intervention by reference in each of the other sections.
11	The form does NOT contain any of the following language: A. “Do not transfer the patient” B. “Do not call 911” C. Any language that could be interpreted as restricting or negating a patient's right to access comfort care. D. Language defining or qualifying “futility.”	Form must not include prohibited language such as “do not transfer” or include a definition of futility. Several forms used the phrase “do not transfer the patient” with qualifiers such as “unless needed for comfort care,” which was deemed compliant.
12	The form is uniquely identifiable (e.g., unique color) and standardized within the state.	Met if there was one form used within and throughout the state. If more than one version of a form was made officially available, then the state was considered partially compliant.
13	The form indicates on the front page (ideally all pages) the name of the state.	Form must note state name on at least one side of the form, and on every page that contains clinical information.
14	Language should be positive and easily understood. [e.g., the comfort measures description might read “Treat with dignity and respect. Keep clean, warm, and dry. Use medication by any route... “and should avoid negative language suggesting that care and/or comfort of the patient are being denied, “Do not intubate or transport. …“].	Compliance required nonoffensive language, language that is easily understood by healthcare providers, and language that would not cause confusion.
15	The original form need not be present at the time of emergency. Form should explicitly state that faxed, copied, or electronic versions of the form are legal and valid.	Despite element requirement to explicitly state “faxed, copied, or electronic versions... [are] valid,” form element was met when there was an indication that the original form was not required. For example, if the form failed to state that electronic versions of the form were valid, but generally indicate the original was not necessary and a copy of the form was valid, the form was considered compliant.
16	The form should NOT contain the following language: Form is rescinded during surgeries, invasive procedures, and/or hospital stays.	Language could not be present on form.
17	All medical orders should be on the first page of the form.	First page of form must include all information relevant for the orders to be valid, including signatures.
18	The form should have the following language included on them: “HIPAA permits disclosure to healthcare professional as necessary for treatment.”	Forms were considered compliant when they fulfilled the spirit of the language. Although not required, the National POLST Paradigm indicated a preference for the language to be clear at the top or bottom of the form.
19	As allowed by statute and regulations, POLST forms should require the patient's (or patient's surrogate): (a) signature; (b) attestation; or (c) witnessed verbal consent. Requiring one of these items provides evidence that the patient or his/her surrogate have reviewed the form, agree with the orders on the form, and that the orders accurately convey their preferences. To increase accountability, it is especially important that programs being established without a governing state statute or regulation develop a process for POLST Form completion that documents review and approval of the form by the patient or the patient's surrogate has occurred.	Form must include language requiring the signature, attestation, or witnessed verbal consent. Additionally, there was no requirement to indicate that the patient must sign or otherwise indicate consent. This could be included in the instructions, the general section, or the specific field.
20	The form should provide information on how to obtain additional forms.	Form must include information about where additional forms could be obtained; listing a website on the form was not considered sufficient without explicit indication that additional forms could be located on the website.
21	The form should provide direction and have specific sections for: (a) completing the form; (b) using the form; (c) updating the form; (d) revoking or voiding the form; and (e) submission to the Registry (if applicable). Directions on revocation or voiding the form should be kept separate for easy navigation.	Forms were evaluated based on the presence of all four sections or inclusion of information about each of the four elements, irrespective of order or organization. Partially compliant forms addressed a majority but not all of the recommended topics.
22	There should be a section next to the date of the healthcare professional's signature for the time of completion. The time of the completion of the form should be entered in addition to the date to comply with good practice and regulations in most healthcare settings.	Forms must include a time field or indicate the need to document the time in addition to the date.

CPR, cardiopulmonary resuscitation; IV, intravenous; POLST, Physician Orders for Life-Sustaining Treatment.

References

Hickman

, Keevern

, Hammes

: Use of physician orders for life-sustaining treatment (POLST) in the clinical setting: A systematic review of the literature. J Am Geriatr Soc, 2015; 63:341–350.

The National POLST Paradigm Program: 2017; www.polst.org (Last accessed August 24, 2017).

The Institute of Medicine: Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life. Washington, DC, 2014.

The Dartmouth Atlas: 2017; www.dartmouthatlas.org/data/region (Last accessed August 24, 2017).

Sabatino

, Karp

: Improving Advanced Illness Care: The Evolution of State POLST Programs: 2011; http://assets.aarp.org/rgcenter/ppi/cons-prot/POLST-Report-04-11.pdf (last accessed March 30, 2018).

The National POLST Paradigm Legislative Guide: http://polst.org/wp-content/uploads/2017/02/2014.02.20-POLST-Legislative-Guide-FINAL.pdf (Last accessed August 24, 2017).

Hickman

, Sabatino

, Moss

, Nester

: The POLST (Physician Orders for Life-Sustaining Treatment) paradigm to improve end-of-life care: Potential state legal barriers to implementation. J Law Med Ethics, 2008; 36:119–140.

Teno

, Sabatino

, Parisier

, et al.: The impact of the Patient Self Determination Act's requirement that states describe law concerning patient rights. J Law Med Ethics, 1993; 21:102–108.

Hickman

, Nelson

, Perrin

, et al.: A comparison of methods to communicate treatment preferences in nursing facilities: Traditional practices versus the physician orders for life-sustaining treatment program. J Am Geriatr Soc, 2010; 58:1241–1248.

10.

Hickman

, Nelson

, Moss

, et al.: The consistency between treatments provided to nursing facility residents and orders on the physician orders for life-sustaining treatment form. J Am Geriatr Soc, 2011; 59:2091–2099.

11.

Chen

, Azueta

: Clarity or confusion? Variability in uses of “Allow Natural Death” in state POLST forms. J Pall Med, 2017; 20:695–696.