An 84-year-old woman in the intensive care unit asked if the facility had a copy of her advance medical directive to support her healthcare wishes. The doctor explained that, in the hospital, this legal document did not serve the purpose she intended and instead detailed the importance of a POLST, or portable medical orders for life-sustaining treatment. The state of Virginia adopted this document in 2023, modeled after the Oregon POLST form which has been in use for more than 20 years.
While advanced directives and portable medical orders appear similar, the differences between the two are consequential when considering a patient’s healthcare at the end of their life.
David Kamer, an attorney with Kaufman & Canoles, outlines the importance of having an advance directive, which is comprised of two elements: a health care power of attorney and health care instructions. In an advance directive, an individual names one or more agents who are given the power to make health care decisions on the individual’s behalf if this person is unable to make an informed decision. The individual can decide what types of powers the agent can have. Examples include whether the agent should have the power to admit this person to a mental health care facility or whether the agent should have the power to decide on a specific treatment even if this person objects.
“An advance directive is also an opportunity to provide specific instructions about care after a person is no longer able to make decisions. It provides instructions about end-of-life care – meaning, whether to provide life-prolonging procedures, such as tube feeding, IV fluids, or use of a ventilator. But it might also be instructions about things such as who is permitted to visit, types of music to play, specific physicians to use, or specific types of treatment to use or not use. In addition, an advance directive can be used to provide instructions about organ donation,” Kamer says.
In contrast, a POLST is a physician-signed order form which communicates and puts into action treatment preferences, such as cardiopulmonary resuscitation orders when a patient is near the end of their life. The Virginia POLST website recommends this form for those with a terminal illness, or those dealing with a chronic progressive illness, such as advanced heart or lung disease or cancer that has spread. Medical orders like POLSTs can be consulted in an emergency, such as in an ambulance or by an emergency medical professional.
Dr. Rosie Newman, a retired geriatric and inpatient palliative care physician, completed a POLST form four to six times per day during the last five plus years of her medical career. “This (the POLST) spells out the desire to avoid interventions focused on life support and rather focused on comfort and a natural death,’ she says. “This is care that aims to remain out of hospital except when comfort cannot be provided in another setting.”
The current standard of care during an emergency is to do everything possible to save someone’s life unless there is a medical order to the contrary. A POLST is based on the ethical principle of respect and patient autonomy and the legal principle of patient self-determination. According to its website, all competent adults have the right to make their own healthcare decisions. A POLST is designed to help healthcare professionals know and honor the treatment wishes of their patients.
Dr. Marissa Galicia-Castillo, director of the Glennan Center for Geriatrics and Gerontology, also serves as the director of the Brock Fellowship in Hospice and Palliative Medicine (which she was instrumental in establishing) and serves on the board of Dozoretz Hospice House of Hampton Roads. She outlines that an advanced care plan provides guidelines for medical care, but it is not an order like a POLST. (Other acronyms for similar orders include POST, MOST and MOLST, and Virginia will accept these documents from other states, as well).
The POLST form simply asks how the individual wants to be treated at the end of life: comfort measures only, selective treatments, or full treatment including artificial nutrition and hydration. “We try to fill-out POLSTS as often as we can, but people don’t want to talk about it,” Dr. Galicia-Castillo says. Since a serious illness often results in palliative care, she recommends having this conversation when the patient is as well as possible and not in distress.
Kamer recommends that everyone also have an advance directive. “The Virginia Code sets out an ordering of who serves as agent to make health care decisions in the absence of an advance directive, but that agent might be someone who would not have otherwise been chosen,” he says. Without an advance directive, a person’s wishes about end-of-life care or other types of health care might not be carried out, as they will be unknown to the agent and the health care providers.
An advance directive can be created online, and Kamer recommends using the form available on the Virginia State Bar website or forms made available by hospitals. However, a lawyer can be helpful in explaining the concepts contained in an advance directive. A POLST, on the other hand, should be obtained from, and completed with, a health care professional. It should not be provided to patients or individuals to complete on their own.
Connect Virginia is a state registry for advance directives where Virginia residents can securely store their completed documents. Health care providers and designated persons can have access to the account. Kamer adds, “To ensure that all relevant parties know about someone’s advance directive, aside from registering it, I recommend giving a copy to one’s physicians and named agents. If the person is comfortable with it, I would also suggest giving a copy to family members and close friends or letting them know where to find a copy.”
While 30+ states recognize the National POLST form, there is no national registry. In Virginia, the form can be uploaded to Sentara’s EPIC system, free of charge, while other hospital systems charge a fee for the upload. “It’s a chunky system, not consistent,” Galicia-Castillo says. She also recommends the U.S. Advanced Care Plan Registry, a secure, online database to store advanced directives, including DNRs (do not resuscitate) and POLSTS. Through its mobile app, emergency responders can search a document by address, allowing personnel to review a DNR or POLST before arriving at the scene.
Newman adds, “Sadly it was not unusual to have this document missing between the hospital and the rehab site – making my job one of calling to be sure the staff saw the POLST and that a copy was now on file in this new setting. Which is why we say transitions of health care locations are the weakest link in healthcare where things can go wrong despite all the best efforts at both sides.”
Both Kamer and Galicia-Castillo stress that a person is never too young to prepare these documents. “It should become a normal part of becoming an adult,” says Galicia-Castillo.
Kamer agrees, “It can be difficult and uncomfortable to think through these serious issues, particularly for young adults, but life is unpredictable. It’s better to get through it and put the subject out of mind than to never deal with it.”
Medical Directives versus Medical Orders
