Understanding the POLST/MOLST Form - Who Needs it and Why
by Don Drake, Connelly Law Offices, Ltd. 5.15.24
"The POLST, which stands for Portable medical Orders for Life-Sustaining Treatment, is a nationally recognized form that allows individuals to specify their preferences regarding life-sustaining treatments," stated professional fiduciary and certified elder law Attorney RJ Connelly III. "In many states, it is commonly called the MOLST, which stands for Medical Orders for Life-Sustaining Treatment. Regardless of the name, the form's purpose remains to control individuals' medical treatment preferences, even outside the medical office. This allows the order to be considered similar to a physician's prescription. However, it's important to note the context behind this blog and why we've chosen to discuss it now."
Recently, a group of seniors attended a presentation by Attorney Connelly on advance directives, living wills, and the POLST/MOLST form. During the presentation, some group members expressed confusion regarding the purpose of the POLST/MOLST form.
Attorney Connelly explained that the form is considered a medical order, similar to a prescription, which medical providers complete only after an appropriate conversation with the patient or the patient's representative. He added that the form's decision-making process is intended for patients with serious life-limiting medical conditions as specified on the National POLST website. However, some members of the group took issue with this explanation.
The conversation became spirited as the group argued that the POLST/MOLST form should be available regardless of age or pre-existing medical conditions. They based their argument on the explanation of the form provided by their "friends."
Attorney Connelly emphasized that providing a POLST/MOLST form to a healthy 25-year-old would be illogical. He cited the fact that in cases where paramedics can save the individual's life, such as in the event of an electric shock or accidental drug overdose, withholding care would constitute medical malpractice.
He also deemed the disagreement necessary because it provided an opportunity to gain a deeper understanding of the form and its appropriate use. Attorney Connelly stated, "It has become evident that there is a need for a comprehensive understanding of this particular form, its intended utilization, and the underlying rationale. The recent divergence of opinions provided an invaluable opportunity to expound upon the intricacies of this form, dispelling prevailing misconceptions and enhancing overall clarity."
Understanding the purpose of this form is significant, as it is often misunderstood, even by some senior care providers. Understanding its historical development is crucial for a better grasp of the POLST/MOLST.
The History of the POLST/MOLST
In 1991, a group of medical ethicists in Oregon recognized that patients' end-of-life wishes were not consistently being honored. While advance directives were helpful for some, these orders were insufficient for individuals with serious illnesses or chronic conditions. To address this issue, a new tool was developed to respect these patients' end-of-life desires.
After evaluating the form's efficacy in the field, the program was referred to as Physician Orders for Life-Sustaining Treatment (POLST). The National POLST form functions as a portable medical order and is completed only after a decision-making process occurs with the patient and/or their representative. It is intended for those who are at risk for a life-threatening clinical event because they have a life-limiting severe medical condition.
In 2017, a new governance structure was established to encourage greater involvement from all fifty states in the initiative. At that time, the "P" in POLST was altered from Physician to Portable to reflect the form's nature better. Presently, the National POLST office is headquartered in Washington, DC.
The Purpose of the POLST/MOLST
As previously mentioned, POLST and MOLST forms are identical, differing only in name based on geographical location. Although the acronyms vary, they function as Medical Orders for Life-Sustaining Treatment and are universally applicable. While the forms may differ in appearance across certain states, their purpose remains consistent, and it is critical to understand their intended use.
The National POLST office advises that individuals with a serious illness and a life expectancy of less than one year should complete a POLST/MOLST form. However, Attorney Connelly suggests that this may be the source of some confusion, as individuals of any age who meet this criterion may obtain a POLST/MOLST form, but only if they have a life-threatening condition.
Patients admitted to hospital care with a life-threatening condition will be asked to complete a POLST/MOLST form. Additionally, many assisted living and skilled nursing facilities require a POLST/MOLST form to be on record. In any case, it is essential that the form is reviewed with the patient and/or their representative and is signed by a physician or medical provider, like a prescription, for it to be considered valid.
Medical Orders for Life-Sustaining Treatment (MOLST) and physician orders for life-sustaining treatment (POLST) forms are critical documents that outline the medical interventions a patient wishes to receive during their illness. These interventions may include intubation and ventilation, cardiopulmonary resuscitation (CPR), tube feeding and artificial hydration, hospital transfer, comfort care, intermittent use of antibiotics, and dialysis.
It is important to note that most POLST/MOLST forms have a "no preference" option. However, checking this box does not guarantee that medical interventions will not be administered if they conflict with the patient's wishes. As such, it is essential for patients and their healthcare providers to have open and honest conversations about their treatment preferences to ensure that the medical care they receive aligns with their values and goals.
Notably, POLST/MOLST forms can be printed on any color paper, including white, which was implemented during the pandemic. However, it is strongly recommended that the users of these forms print them on bright-colored paper to ensure visibility and place them in a conspicuous position at the front of the chart.
Emergency Medical Services (EMS) and paramedics are equipped with the skills to recognize POLST/MOLST forms in the community. Once they identify the form, they are obliged to abide by its instructions. Therefore, it is highly recommended to print the form on bright-colored card stock and keep it in a visible location, such as a refrigerator door. By adhering to this practice, individuals can ensure that their POLST/MOLST forms are easily located and followed by medical professionals.
Is the POLST/MOLST an Advance Care Directive?
"The POLST/MOLST form functions as a medical document containing specific medical orders that are immediately actionable based on a patient's current medical condition," said Attorney Connelly. "Unlike advance directives, which are legal documents that take effect only after a patient has lost capacity, the MOLST form is signed by both the clinician and the patient, and its directives become effective as soon as it is signed, regardless of the patient’s capacity to make decisions. This immediate effectiveness differentiates it from traditional advance directives, such as health care proxies and living wills."
The MOLST form remains in effect even if the patient has decision-making capacity. This means that the patient can still receive necessary medical treatment regardless of what the MOLST form specifies. Additionally, the patient has the right to revoke the MOLST form and request a healthcare professional to fill out a new form with updated instructions at any time.
Starting the Conversation
"If you want this document in place, you can start by having an open and honest conversation with your doctor, nurse practitioner, or physician assistant about your current medical conditions, prognosis, and potential future treatment options," Attorney Connelly stated. "After discussing your medical situation with your healthcare professionals, it's time to talk with your family members or anyone else you trust and feel close to. Together, you can decide what medical treatments align with your wishes and which ones you prefer to avoid. All decisions must reflect your personal preferences, values, and long-term goals."
The POLST/MOLST in Southern New England
Attorney Connelly indicated that despite the differences in wording, state standards share the same intent. Additionally, it is essential to note that a POLST/MOLST form is unsuitable for a healthy individual, and chances are slim that a doctor would approve one in such cases anyway. Thus, it is important to review each state's standards thoroughly.
RHODE ISLAND
CONNECTICUT
MASSACHUSETTS
A Final Word
"I cannot emphasize enough the importance of having your advance directives in place to ensure that your medical and end-of-life care preferences are followed in case you cannot communicate them," said Attorney Connelly. "However, it's just as important to follow your state's direction regarding completing the POLST/MOLST form if you meet the necessary criteria."
Start by having an open and honest conversation with your doctor, nurse practitioner, or physician assistant about your current medical conditions, prognosis, and potential future treatment options. You may also want to speak with other healthcare professionals, such as social workers, nurses, or chaplains, who can provide valuable support and information.
After discussing your medical situation with healthcare professionals, talk with your family or anyone you trust and feel close to. Together, you can decide what medical treatments align with your wishes and which ones you prefer to avoid.
"When making these decisions, ensure they reflect your personal preferences, values, and long-term goals," Attorney Connelly continued. "Remember that you have the right to agree or disagree with any medical treatments recommended, and your healthcare team should respect and support your decisions."
Please note that the information provided in this blog is not intended to and should not be construed as legal, financial, or medical advice. The content, materials, and information presented in this blog are solely for general informational purposes and may not be the most up-to-date information available regarding legal, financial, or medical matters. This blog may also contain links to other third-party websites that are included for the convenience of the reader or user. Please note that Connelly Law Offices, Ltd. does not necessarily recommend or endorse the contents of such third-party sites. If you have any particular legal matters, financial concerns, or medical issues, we strongly advise you to consult your attorney, professional fiduciary advisor, or medical provider.
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