No doubt about it, when it comes to starting your end-of-life plan, you may be confused as to which documents you should keep at the ready. Some of these include the MOLST, POLST, Living Wills, and Advance Directives. A MOLST, or Medical Orders for Life-Sustaining Treatment form or a POLST, known as a Physician Orders for Life-Sustaining Treatment can help, but only during specific situations at the end-of-life.
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Nationally consistent forms would help clarify these critical documents, but each state has the authority to design what they want. Because of this, not everyone needs a MOLST or POLST unless they are hospitalized or at the end of life. However when it comes to those circumstances, it is vital to have one and some hospitals require it.
It can help to determine what your state uses so you are familiar with the form before you need it. Everyone, regardless of medical status, should do advance care planning and be familiar with their MOLST or POLST form. Reviewing it can help you start to understand the realities and complexities of interventions at the end of life.
Are MOLST and POLST Forms the Same?
MOLST and POLST forms are the same. They just have different names depending on what state you live in. A MOLST definition is Medical Orders for Scope of Treatment, and a POLST definition is Physician Orders for Scope of Treatment. They can both be otherwise known as Medical Orders for Life-Sustaining Treatment or Physician Orders for Life-Sustaining Treatment (POLST).
Each state’s form will look different, but the intent is the same, and it is important to understand under what circumstances these forms are used. On the whole, you should have either a MOLST and POLST form filled when you are seriously ill or have less than a year to live.
If you are admitted to the hospital with a life-threatening condition, you will be asked to fill out a MOLST or POLST form. Some assisted living and nursing home facilities also require a MOLST or POLST. Regardless, a physician or other designated healthcare provider must review and sign the document.
These forms specify what treatment you want to receive during your illness. This includes instructions for the following, but is not limited to:
- Intubation and ventilation
- Tube feeding and artificial hydration
- Hospital transfer
- Comfort care and intermittent use of antibiotics
Each option for interventions also has questions about the circumstances under which you may want life-extending treatment, such as using artificial hydration for the short term only. Most MOLST and POLST forms also have the option to state no preference, but this could lead to medical interventions that you do not want.
Both the MOLST and POLST documents are printed on bright colored paper so they are easily recognizable by healthcare providers and can be placed at the front of a patient’s chart. When either is filled, these forms go into effect immediately and supersede any prior advance directives, except in just a few states.
However, if you recover and go home or to another care center, you may want to do another MOLST or POLST form since your wishes may have changed.
Are they advance directives?
Everyone over the age of 18 should have advance directives. Advance directives, just like MOLST and POLST forms, have different names in each state. Advance directives are also called living wills, health care proxy, healthcare power of attorney, healthcare surrogate, or medical power of attorney.
Advance directives help to state the following:
- Allow you to name who you want to make medical decisions should you become incapacitated. Or, in some cases, it allows a designated person to obtain and give medical information immediately.
- You can state the limits to medical interventions depending upon the circumstances. Not all states have advance directives that indicate end-of-life wishes, so you may need to complete a different form for that purpose.
- The naming of a guardian should you become incapacitated.
A MOLST and POLST form does not allow you to designate a healthcare proxy in the event of incapacity. Their intended use is for the current circumstance of urgent illness or impending end of life. Your stated wishes on your advance directive may reflect your wishes when you are healthy.
If your health status changes dramatically, you will want to fill out a MOLST or POLST form. For example, your advance directive might state that you want CPR. However if your status changes, you can rescind it by indicating on your MOLST or POLST that you do not wish to have CPR.
Are there other names for these forms?
To add to the confusion, there are other names for these forms, and they are state-specific. The other two most common names are COLST (Clinician Order for Life-Sustaining Treatment) and TPOPP (Transportable Physician Orders for Patient Preferences).
Others are MOST (Medical Orders for Scope of Treatment) in Colorado and North Carolina, IPOST (Iowa Physician Orders for Scope of Treatment) in Iowa, and LaPOST (Louisiana Physician Order for Scope of Treatment) in Louisiana. As you can see, each state has different names for these forms, but most use either the term MOLST or POLST.
In What Instances Are MOLST and POLST Forms Different?
Even though MOLST and POLST forms have the same intent, they may be structured and worded very differently. Here is an example of a MOLST vs. a POLST.
Maryland has a MOLST form that, in part states:
“Option A-1, Intubate: Comprehensive efforts may include intubation and artificial ventilation. ________ Option A-2, Do Not Intubate (DNI): Comprehensive efforts may include limited ventilatory support by CPAP or BiPAP, but do not intubate.
No CPR, Option B, Palliative, and Supportive Care: Prior to arrest, provide passive oxygen for comfort and control any external bleeding. Prior to arrest, provide medications for pain relief as needed, but no other medications. Do not intubate or use CPAP or BiPAP. If cardiac and/or pulmonary arrest occurs, do not attempt resuscitation (No CPR). Allow death to occur naturally.”
Minnesota has a POLST form that in part states:
“Full Treatment. Use intubation, advanced airway interventions, and mechanical ventilation as indicated. Transfer to hospital and/or intensive care unit if indicated. All patients will receive comfort-focused treatments. TREATMENT PLAN: Full treatment including life support measures in the intensive care unit.
Selective Treatment. Use medical treatment, antibiotics, IV fluids, and cardiac monitor as indicated. No intubation, advanced airway interventions, or mechanical ventilation. May consider less invasive airway support (e.g. CPAP, BiPAP). Transfer to hospital if indicated. Generally, avoid the intensive care unit. All patients will receive comfort-focused treatments. TREATMENT PLAN: Provide basic medical treatments aimed at treating new or reversible illness.
Comfort-Focused Treatment (Allow Natural Death). Relieve pain and suffering through the use of any medication by any route, positioning, wound care, and other measures. Use oxygen, suction, and manual treatment of airway obstruction as needed for comfort. The patient prefers no transfer to the hospital for life-sustaining treatments. Transfer if comfort needs cannot be met in the current location. TREATMENT PLAN: Maximize comfort through symptom management.”
These are just partial examples from two different states to give you an idea of the differences in language each state uses. However, some state forms are easier to understand and fill out than others. Each one is attempting to give an individual as many options as possible in making these difficult decisions.
If you are conscious and have the capacity to change your mind regardless of what the MOLST or POLST states, you can do that. However, should you become unconscious, you may want to make certain that you have thought through reasonable interventions. Here are some suggestions to keep in mind on how to make decisions on a MOLST or POLST.
Talk with the doctor who is treating you
No one knows exactly how the course of your disease or condition will go, but you have a right to know what your prognosis is. If there is no meaningful chance of returning to a quality of life, this can guide your decisions. If you do not designate that you are Do Not Resuscitate (DNR), every effort will be made to resuscitate you even if it causes irreparable harm.
Ask your doctor what comfort measures are reasonable. For example, treatment with antibiotics for a urinary tract infection might be considered comfort care since it doesn’t prolong life but addresses discomfort.
Talk with your family, friends, or religious/spiritual advisors
If you are uncertain or confused, talk openly with trusted family members or friends. Discuss the pros and cons of interventions. If you choose to refuse treatment, it can be a very challenging decision for some people to hear, and can bring up feelings of loss and grief.
Understand that you can change your mind. Nothing is engraved in stone. If your medical situation stabilizes, ask to fill out another form where you can make changes consistent with your changing medical status.
Knowing the Value of a MOLST and a POLST
Now that you understand the different names for these directives, you can review the one for your state. Regardless of where you are, whether it is home, hospital, nursing home, or assisted living, you need an advance directive and in some cases, a MOLST or POLST.
You should be the one to decide how you want your end of life to be. It can be painful to make these decisions, but they are yours to make.
- “Maryland MOLST.” Marylandmolst.org, marylandmolst.org/pages/molst_form.htm
- “POLST Minnesota.” Minnesota Medical Association, www.mnmed.org/advocacy/improving-health-of-minnesotans/POLST-Communications