Advanced care planning, or the process of documenting an individual’s preferences for medical care, is one helpful way to understand a patient’s preferences better when they may be otherwise incapacitated. Often, living wills are used as an advanced care planning tool in the US, but the number of individuals completing living wills or other advanced care plans “remains low (i.e., <30% completion rate)” according to studies, and as many as 70% of individuals at the end of life “lack the capacity to communicate their preferences due to the progressive and advanced nature of their illnesses (e.g, dementia or stroke).” A higher awareness and more education on different advanced care planning tools are important so patients and families can make the patient’s wishes for end-of-life care explicit and avoid mistakes or mistreatment in the most critical times of a patient’s care.

Two such tools that share very similar means and can be extremely helpful for patients are the Provider Order for Life-Sustaining Treatment (POLST) and the Medical Orders for Life-Sustaining Treatment (MOLST). These documents differ from most advanced care orders in that they target “people who are suffering from advanced, progressive illness and/or frailty, and living with limited life expectancy.” While living wills are for any adult 18+ years and older regardless of medical status, POLST/MOLST are tools focused on patients who have received a terminal diagnosis and are entering end-of-life. 

In this piece, we will discuss what POLST/MOLST are, how they differ from each other, if POLST/MOLST are right for you or your loved one, and how to enroll in them. If you have any further questions, please contact Heart to Heart, and we can answer questions you might have.

What are the differences between MOLST and POLST?

MOLST and POLST are documents with very similar aims, but they are viewed in different ways depending on the area of use in the United States. Let’s start with some definitions of each.

MOLST, as stated previously, is an acronym for Medical Orders for Life-Sustaining Treatment. The MOLST Program is “an initiative to facilitate end-of-life medical decision-making in New York State, Connecticut, Massachusetts, Rhode Island, Ohio, and Maryland, that involves use of the MOLST form.” It 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.”

POLST is an acronym for Provider/Physician/Portable Order for Life-Sustaining Treatment. POLST has slightly different names in different states, but the purpose is the same: to communicate a seriously ill or frail patient’s wishes for end-of-life intervention to health care facilities and providers, including emergency medical services (EMS). 

This full list of POLST programs by state includes the latest information for each state and the District of Columbia. Those programs are run by the individual states. The order is valid outside of a clinic or doctor’s office, similar to a prescription, and is meant to travel with the patient to all health care settings. The POLST program seeks to “use one style of form applicable across all health care settings, signed by a patient (or their surrogate) and their health care providers.” 

Overall, both of these forms (MOLST/POLST) are interchangeable and can be used across health care settings. They can be used in hospitals, hospice, and nursing homes to issue any orders concerning life-sustaining treatment. The forms may also be used to issue non-hospital DNR and DNI orders, and other life-sustaining treatments. They help answer such questions as:

  • Do you want CPR performed if your heart stops?
  • Do you want to go to the hospital if you’re not already there? Or stay where you are?
  • Do you want to be put on a machine if you can’t breathe on your own?
  • Do you want a feeding tube if you can’t chew or swallow?
  • Do you want antibiotics if you have an infection?
  • Do you want aggressive treatments at all costs?
  • Do you want comfort care only?

Who needs MOLST/POLST?

These forms and processes are great tools for patients, but they are not for everyone. According to National POLST, the organization that first began advocating for this process, it was created for patients “whose medical conditions mean they are likely to have a medical emergency, and they likely know what that emergency will be.” This includes people who:

  • Are at risk for a medical emergency based on their current medical condition
  • Have had multiple unplanned hospital visits in the last year
  • Have been diagnosed with a serious illness such as severe heart disease, metastatic cancer, advanced lung, renal, or liver disease; advanced dementia, and other conditions; or
  • Recognizes their advancing condition is significantly limiting their ability to perform activities of daily living

Similarly, the MOLST program describes suitable patients as “person[s] of any age (including children) who [are] at the end stage of a life-limiting illness or in a condition of advanced progressive frailty who wants to express their preferences about life-sustaining medical treatments.” It goes on to say that every person who is at the end stage of a life limiting illness or in a condition of advanced progressive frailty “[should fill out the form] if: it is medically appropriate, based on the person’s current health condition as determined by a physician or APRN and the person wants to express preferences about life-sustaining medical treatments.”

Both of these definitions encompass patients who are eligible for hospice care. It is important to have the conversations necessary to fill out the necessary (and appropriate, depending on where the patient lives) forms, including legal counsel where appropriate. The earlier the conversation can occur, the better, so the patient can have a say in their treatment. Many patients may struggle to communicate when the time comes, and in those moments, having a living will with answers to some of the aforementioned questions could be helpful. The responses can be transferred over to a MOLST/POLST for medical personnel. 

How do I enroll in and set up MOLST/POLST?

Now that you have some background on these programs, you can set up a MOLST/POLST form for you or your loved one. Below are quick checklists for both programs that can help you get started, along with links for further information on filling out the right forms for enrollment.

How to Enroll in MOLST

The New York State Department of Health provides an 8-step protocol for the MOLST form. It includes a link to the correct form to fill out with your medical provider. The steps are:

  1. Prepare for Discussion – collect patient information, goals, etc., that you’ll need to fill out the form
  2. Begin with what the patient and family know about the patient’s condition 
  3. Provide any new information about the patient’s medical condition from the medical team’s perspective
  4. Try to reconcile differences in terms of prognosis, goals, hopes, and expectations
  5. Respond empathetically – these conversations are often stressful and emotional, so staying empathetic throughout is important for everyone involved in the conversation.
  6. Use MOLST to guide choices and finalize patient and/or family/close friend wishes
  7. Complete and sign the MOLST form
  8. Review and revise periodically – the program recommends a review every 90 days in case the patient’s medical history has changed and new rules need to be put into place

How to Enroll in POLST

Similar to the NY Department of Health, the National Council on Aging provides a helpful explanation on how to create a POLST for the patient. That explanation is as follows:

First, have an honest conversation with the patient’s physician regarding medical condition, prognosis, and treatment wishes. Include family, caregivers, and anyone else involved in the patient’s care.

Next, the patient’s physician can walk everyone through filling out the form. POLST forms differ state to state, but all include four basic sections:

  • Section A: If the patient wants the medical team to perform CPR if their heart stops
  • Section B: If the patient wants the medical team to incorporate medical interventions. This is in situations where the patient’s heart is still beating, but they are critically ill. This section covers preferences on where the patient wants to receive treatment, and what types of care they’d like to receive
  • Section C: If the patient wants to receive antibiotics in the case of a life-threatening infection
  • Section D: If the patient cannot eat or drink on their own, should the medical team provide artificial nutrition to keep them alive

Once the POLST form is complete, the next step is making copies and sharing them with all applicable medical providers and caregivers. This way, if an emergency arises, the patient’s wishes are available and clear.

Resources for more information on MOLST/POLST

Here are some helpful resources for more information on the MOLST/POLST programs and their availability in your state: