Although advance directives play a key role in determining what kind of care patients wish to receive at the end of their lives, too few Americans—only about 34 percent of U.S. adults— have one. As a result, many patients do not receive end-of-life care that reflects their priorities.
One type of advance directive, Physician Orders for Life-Sustaining Treatment (POLST), can be used to specify treatment preferences for patients in their last year of life. Individuals with a POLST document reflecting their preference for comfort measures were less likely to receive life-sustaining medical intervention compared with those who had either wanted all medical measures to be taken or had not filled out a POLST form.
To increase the use of this document, the National POLST Paradigm, a nonprofit that sets core requirements for state-based programs, recently released a toolkit to make it easier for physicians and patients to integrate POLST into conversations about preparing for the end of life. The document, which was funded by The Pew Charitable Trusts, includes guidance for providers in each of the following settings:
The POLST toolkit offers instructions to providers on how to initiate the program for people near the end of life. Additionally, it addresses several common misconceptions about POLST and how to best use it. For example, the toolkit clarifies that the POLST should be used only for patients whose health care professionals would not be surprised if they died within one year, while an advance directive is appropriate for all patients to record their end-of-life priorities. POLST also differs from an advance directive in that it is a medical order recognized across state lines.
Forty-nine states have authorized some form of POLST program; South Dakota and Washington, DC, have not done so but do recognize the POLST form. Several states have developed regional pilot programs or have implemented the POLST paradigm so it is their state’s standard of care, while others have simply passed legislation.
To ensure that individuals with serious illness get the care they prefer, they need access to the proper advance care planning form. Their physicians likewise require access as well as training to lead effective conversations with patients and their families in order to understand a patient’s preferences for care. The information in this toolkit can help ensure that patients who are in their last year of life get the care they want.
Lee Goldberg directs Pew’s improving end-of-life care project.