State POLST Maturity and Advance Directive Completion

Topic: Quality Advance Care Planning


Beyond advance directives, the presence of a completed POLST form assures a greater likelihood that an individual's preferences for medical treatment will be honored at the end of life.1,2 For more than 10 years, the National POLST Paradigm Task Force has assisted states in developing quality standards for POLST programs. To date, 19 states have endorsed POLST programs, 25 have developing programs and 3 states have programs that do not conform to requirements.3 Using a large multi-state community-based palliative care program, we analyzed records from 71,768 nurse practitioner home visit encounters on 11,634 patients for presence of advance care planning conversation and completion of an advance directive (ie any state approved living will and/or POLST form).   All care was provided by advance practice providers working for the same palliative care company in 1 of 4 states (two with endorsed POLST status (PA and TN), one with a developing POLST program (TX) and one whose program does not currently conform to POLST requirements (AL).  All staff received standardized training in communication and documentation of goals of care and advance directive completion. All patients received program education packets that included a copy of a state approved advance directive.  In POLST program states, staff were also provided with a copy of the state's POLST form.   Across all states, advance care planning was addressed at an average of 81.67% of advance practice provider home visits (range 66.99% TN to 94.94% PA).  Yet, documentation of patient treatment preferences was completed preferentially in the endorsed states over the developing state (TN 70%, PA 72% vs TX 39.9%) and the non-conforming state (AL 26.8%).  This data demonstrates a correlation between the maturity of a state's POLST program and the completion of any advance directive document and support the efforts of the National POLST Paradigm Task Force.

1Bomba PA, Kemp M. Black J.  POLST:  An improvement over traditional advance directives.  Clev Clin J of Med 2012; 79.7: 457-464.

2 Hickman SE, Nelson CA, Perrin NA, et al.  A comparison of methods to communicate treatment preferences in nursing facilities:  traditional practice vs the physician orders for life sustaining treatments program.  JAGS 2010; 58: 1241-48.




  • Tara Friedman, MD, FAAHPM

If you need assistance, please use the customer support form.