Advance Directives vs. POLST
Both advance directives and POLST forms
are advance care plans. They complement
each other but work in different ways. All
adults with capacity should have an advance
directive documenting a Health Care Power
of Attorney (HCPOA) and a Living Will. An advance
directive serves as a guide for when a patient
can no longer make decisions for him or
herself. Only patients with a limited life expectancy
(<1 year) are eligible for a POLST. Both
patients with capacity and surrogates for patients
without capacity can complete a POLST,
which serves as an actionable order set. Table
1 summarizes the differences between the two
documents.
Ethics Surrounding POLST
The POLST Act recognizes that allowing
natural death to occur is not the same as actively
hastening death. POLST forms do not
allow for euthanasia or physician-assisted
suicide. Completing a POLST form is voluntary
and should be done in conjunction with
a goals-of-care conversation with a physician.
A POLST can be voided or changed at
any time, and physicians should review the
form and goals of care with a patient or their
surrogate periodically to confirm that goals
are still the same.
Practical Guide for
Arkansas Physicians
POLST is a state-specific form. Hospitals
or other institutions may elect to honor out-ofstate
forms, which should be described in institutional
policy. We recommend that physicians
encourage completion of an Arkansas POLST if
a patient has a POLST form from another state.
Physicians are encouraged to have discussions
with their patients with a limited life expectancy
about diagnosis, prognosis, and goals of
treatment in a shared decision-making model.
Completing a POLST form with the patient or
surrogate can ensure that the patient’s wishes
will be honored.
The Arkansas POLST form (Figure 1), with
directions, can be accessed through the Arkansas
Department of Health’s webpage (https://
www.healthy.arkansas.gov/programs-services/topics/polst).
The webpage also contains
a webinar about Arkansas POLST and
links to informational videos for self-directed
learning. The website has an email link for
health care providers to reach out to the state’s
POLST Committee with questions. The National
POLST Paradigm is also a valuable resource
for clinicians and patients or caregivers (www.
POLST.org).
For physicians who are caring for veterans
in the VA Healthcare System (Central Arkansas
Veterans Healthcare System [CAVHS]), the Veterans
Healthcare System of the Ozarks, and
all VA-affiliated clinics), it is important to note
the VA launched a complementary advance
care planning process in January 2018. The
Life Sustaining Treatment Decisions Initiative
(LSTDI) is a nationwide VA program created to
facilitate conversations between health care
teams and seriously-ill veterans regarding
goals of care and options for life-sustaining
Figure 1.
treatment. Nationally, the VA standardized the
documentation and orders related to a Veteran’s
preferences for life-sustaining treatments.
Like Arkansas POLST, the LSTDI allows health
care teams to document the care wishes of veterans
as well as their preferences for life-sustaining
treatments like mechanical ventilation,
artificial nutrition and hydration, hospitalization,
and ICU care. However, there are important
differences between this process and Arkansas
POLST. First, the LSTDI documentation
and orders are only active within a VA setting.
Veterans require additional documentation for
use in the community. We recommend the use
of an Arkansas POLST form. Second, advance
practice nurses, physician assistants, and
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