Updated: Mar 23
Nationally, it is called the POLST, an acronym for Portable medical Orders for Life-Sustaining Treatment. On the state level, it is mostly known as the MOLST, Medical Orders for Life-Sustaining Treatment. In either case, it has the same intent, and the form is portable, meaning that the order is valid outside the medical office, similar to a physician's prescription. But before we move on, it's important to put this blog into some context and why we decided to publish this now.
Late last week, certified elder law Attorney RJ Connelly III, gave a presentation to a group of seniors about advance directives, living wills, and the POLST/MOLST form. During the presentation, a handful of seniors expressed some disagreement on what the POLST/MOLST form was designed for and how Attorney Connelly was presenting it.
"We moved from the discussion of the living will into the MOLST/POLST form," said Attorney Connelly. "I stated that the form is a medical order, written like a prescription that is completed by medical providers only after an appropriate conversation with the patient or the patient's representative. I then added that the form and the decision-making process are for those patients who are at risk for a life-threatening event because they have a serious life-limiting medical condition, which may include frailty, wording that exists on the National POLST website. That's when the fireworks started."
"It became a rather spirited conversation," said Attorney Connelly with a smile. "It was their stance that the POLST/MOLST form is available to anyone of any age and that they do not need any pre-existing conditions to have one. This, according to the group, was based upon the explanation of the form by their medical providers."
Attorney Connelly pointed out that giving a MOLST/POLST to a 25-year-old who is otherwise healthy makes little sense, citing the fact that should a condition such as an electric shock or accidental overdose occur, chances of paramedics saving his or her life are extremely high, so withholding care would border on medical malpractice.
"It became apparent to me at the time that we needed to really understand this form and how it is to be utilized and for what reasons," said Attorney Connelly. "I was glad we had this disagreement because it is an opportunity to present more about this form and eliminate some of the misinformation that exists."
The History of the MOLST/POLST
We go back thirty years to 1991 when a group of medical ethicists in Oregon had concerns about patients and their end-of-life wishes not being honored on a consistent basis. Although advance directives worked for a certain group, these sets of orders were inadequate for those with serious illnesses or chronic frailty, so a new tool was developed that honored these patients' end-of-life wishes.
After evaluating this form and its use in the field, the program became known as the Physician Orders for Life-Sustaining Treatment (POLST). The National POLST form is designed to be a portable medical order, completed only after a decision-making process occurs with the patient and/or their representative, and only for those who are at risk for a life-threatening clinical event because they have a serious life-limiting medical condition, which could include advanced frailty.
In 2017, a new governance structure was put into place, designed to encourage more participation in this project from all fifty states. At that time, the "P" in POLST was changed from Physician to Portable, to better describe the nature of the form. Today, the National POLST office is based in Washington, DC.
The Purpose of the MOLST/POLST
As we stated earlier, the MOLST and POLST forms are really the same. They just have different names depending on where you live. Although the acronyms are different, they can both be known as Medical Orders for Life-Sustaining Treatment and are portable.
Although the forms may look different in some states, the intent is the same, and knowing why they exist and what they are used for is extremely important. The rule of thumb, according to the National POLST office, is that if a person has a serious illness with less than a year to live, they should complete a MOLST/POLST form.
"The rule of thumb, according to the National POLST office, is that if a person has a serious illness with less than a year to live, they should complete a MOLST/POLST form."
"This is where I believe some of the misunderstandings may have arisen," said Attorney Connelly. "Anyone of any age who meets the above criteria can be eligible to obtain a MOLST/POLST form, but they must have a life-threatening condition."
Those entering hospital care who have a life-threatening condition will be asked to complete a MOLST/POLST form. Many assisted living and skilled nursing homes also require a MOLST/POLST form to be on record. In any case, this form must be reviewed with the patient and/or the representative and requires a physician or medical provider's signature, like a prescription, for it to be considered valid.
The MOLST/POLST forms specify what treatment you may want to receive during your illness. This may include:
Intubation and ventilation
Tube feeding and artificial hydration
Comfort care and intermittent use of antibiotics
Most MOLST/POLST forms also have the option to state no preference, but by checking this box, you may still receive medical interventions that you do not want.
MOLST/POLST forms can be printed on any color paper, including white (this was put into place during the pandemic), however those using it are urged to put it on a bright colored paper, so it is recognized and put in the front of the chart.
In the community, Emergency Medical Services (EMS and paramedics) are trained to look for a MOLST/POLST form. If they see it, it will be honored. Therefore, printing it on bright card stock and keeping it where it can easily be seen (like a refrigerator door) is important.
Is the MOLST/POLST an Advance Care Directive?
"No, it's not," stated Attorney Connelly. "Advance directives are legal orders while a MOLST/POLST provides medical orders. During an emergency, presenting a MOLST/POLST to the emergency providers gives them directions as to what treatments are wanted. Without the MOLST/POLST, EMS will do everything in their power to keep you alive until you reach the hospital where the provider and healthcare surrogate can make decisions based on the advance directive."
"Even more important," stated Attorney Connelly, "the MOLST/POLST form gives seriously ill or frail people more specific direction over their health care treatments compared to advance directives and more options than Do Not Resuscitate (DNR) orders."
What About Southern New England?
"When we look at state standards here, although they have different wording, the intent is the same," said Attorney Connelly. "And to reiterate, a healthy person is not an appropriate candidate for a MOLST/POLST form. Let's look at the standards."
RHODE ISLAND - Medical Orders for Life-Sustaining Treatment (MOLST) are instructions to follow a terminally ill patient's wishes regarding resuscitation, feeding tubes, and other life-sustaining medical treatments. The MOLST form can be used to refuse or request treatments and are completely voluntary on the part of patients. These orders can supplement Do Not Resuscitate (DNR) instructions.
CONNECTICUT - MOLST orders are for patients who are at the end stage of a serious life-limiting illness or in a condition of advanced chronic progressive frailty as determined by a physician or advanced practice registered nurse. The MOLST form documents patients’ decisions in a clear manner that can be quickly understood by all providers, including first responders and emergency medical services (EMS) personnel.
MASSACHUSETTS - MOLST is a medical order form (similar to a prescription) that relays instructions between health professionals about a patient's care. MOLST is based on an individual's right to accept or refuse medical treatment, including treatments that might extend life. MOLST is not for everyone. In Massachusetts, patients with a serious advanced illness at any age may discuss filling out a MOLST form with their clinician. The patient's decision to use the MOLST form must be voluntary.
"So, here's the bottom line," said Attorney Connelly. "Have your advance directives in place, but if you meet the criteria necessary for the completion of the MOLST/POLST form, follow your state's direction and have that in place as well."