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Issues at a Glance: Provider Orders for Life-sustaining Treatment (POLST)

What is it?

Provider Orders for Life-sustaining Treatment (POLST) are portable medical orders that communicate to health care facilities and providers a patient’s wishes for end-of-life intervention, including emergency medical services (EMS). A POLST initiative seeks to use one style of form applicable across all health care settings, signed by a patient (or their surrogate) and their health care provider.

Over the past three decades, health care providers, patients and families recognized the growing need for informed conversations and communication tools to help patients define their end-of-life care decisions and advance directives. To address this issue, an Oregon task force developed the first POLST form in 1995. The National POLST organization was created in 2004 to encourage states to adopt similar standardized programs and forms.

Since then, most states have adopted similar standardized programs and forms. The American Association of Nurse Practitioners® (AANP) uses POLST as the association’s standard terminology, although these initiatives may be referred to in a state by a similar variation:

  • POLST or POST (physician/provider orders for life-sustaining treatment).
  • MOLST (medical orders for life-sustaining treatment).
  • COLST (clinician orders for life-sustaining treatment).
  • MOST (medical order for scope of treatment).

A list of all state program names can be found on the National directory.

The goal of POLST is to ensure that patient wishes are known and honored by health care providers, including EMS personnel. POLST is a complement to, but does not replace, advance directives. POLST is appropriate for patients at increased risk of a life-threatening clinical event because they have a serious life-limiting medical condition, which may include advanced frailty.

POLST provides additional specificity about the types of treatments and interventions these patients may wish to receive or avoid. The form requires the signature of both the health care provider and the patient (or their surrogate) to be a valid portable medical order. The patient (or surrogate decision-maker) must agree to have a POLST form. POLST forms are voluntary — it is always the patient’s choice whether to have one.

In addition to honoring a patient’s wishes for their course of treatment, the majority of states have modernized POLST programs to ensure continuity of care by honoring the patient’s choice of clinician on the form itself.

How will it impact my patients and my practice?

As part of an advance directive planning process, POLST and similar programs help patients and their families make their preferences for end-of-life care and treatment interventions known. Care transitions and hand-offs between facilities are simplified and standardized with portable orders, allowing families and clinicians to prioritize the patient over paperwork.

Completing a POLST form is completely voluntary, yet increasingly considered part of routine care. It is incumbent upon nurse practitioners (NPs) to be familiar with POLST forms and state or jurisdiction requirements. Because some state laws still vary in recognition of NP signatures on POLST forms, policy changes to existing and developing POLST programs continue to be necessary.

AANP encourages NPs to be prepared to discuss advance care planning with patients who may be candidates for POLST and to verify that a patient’s end-of-life forms are valid with an NP signature.

Is there a POLST or similar program in my state? Are NP signatures recognized on these forms for patients?

  • Forty-two states and Washington, D.C., have codified their POLST or similar programs into state law or an officially recognized state form.
  • NP signatures are recognized on official statewide forms in 36 states and Washington, D.C.
  • Of the jurisdictions that have an established standardized state form, only six do not explicitly recognize NP signatures on these items of patient care.
  • Eight states do not have an officially recognized, single, statewide POLST form in state law or regulations.

Does statewide POLST authorization mean NPs may sign do-not-resuscitate (DNR) orders in all circumstances?

Not necessarily. According to National POLST: “Some state laws regarding DNR orders only apply when the patient is not in an acute setting (out-of-hospital) and is limited to only those patients already in cardiac arrest or who have stopped breathing.” POLST forms may include DNR language, but they also add additional specificity that is appropriate for a select patient population. POLST allows those patients to expand on traditional DNR by also indicating treatments the patient does want to receive, as well as make arrangements for out-of-hospital settings and clinical events that may not fall under cardiac arrest. See your state statute for detail on NP recognition to sign standalone DNR orders.

Links to Additional Resources

If POLST or another advance directive legislation or initiative is proposed in your state, please contact the AANP State Government Affairs office at 703-740-2529 or via the AANP Help Center. AANP welcomes the opportunity to work with state stakeholders to shape legislation that is beneficial and appropriate for patients, NPs and the entire health care community.

Download This Policy Brief

© American Association of Nurse Practitioners, Revised October 2023