End-of-Life Care Form

Revised (referral change)


CHSO Report 1-A-06
Subject: End-of-Life Care Form
Presented by: Dennis Pacl, MD, Chair
Referred to: Reference Committee on Science and Education


POLST is an acronym for Physician Order for Life Sustaining Treatment. The POLST concept was developed by a task force at Oregon Health and Science University. The task force was concerned that Oregon's law regarding advanced directives was not effective. Thus, the POLST concept was developed to address the problem of " unwanted transfer and intensive medical interventions to those patients who did not want such interventions." The form serves as a method to communicate specific physician orders to be implemented in any facility or environment.

The POLST form, as it is used in Oregon, is not a direct expression of a patient's consent or refusal to consent for care. The form is an actual physician standing order - but also may be executed by a nurse practitioner - and is not a patient advanced directive. There is a signature block on the back to bolster the representations made by the physician or nurse practitioner regarding the patient's desired end-of-life care, but the patient's signature is optional.

Oregon law does not provide any formal status on the POLST form. Indeed, the statutes only authorize advanced directives. The Oregon Board of Medical Examiners, however, promulgated the following regulations to provide some support to POLST:

(6) An Oregon-certified First Responder or EMT, acting through standing orders, shall respect the patient's wishes including life-sustaining treatments. Physician supervised First Responders and EMTs shall request and honor life-sustaining treatment orders executed by a physician or a nurse practitioner, if available. A patient with life-sustaining treatment orders always requires respect, comfort, and hygienic care.

Therefore, Oregon EMTs are subject to discipline should they fail to carry out a POLST. The EMT has no discretion to refuse to honor a physician order (although one would suppose the Oregon board would not discipline for honoring the patient's expressed wishes even if they contradict the POLST).

POLST and Texas Law
TMA has taken steps to ensure that physician orders are not regulated by Texas law. Texas' out-of-hospital DNR law does not limit or address the manner or conditions under which the physician, under his or her authority as a licensed physician, could issue an order not to resuscitate. After the 2003 legislative session, in order to address concerns from nursing homes, an express provision was placed into law stating that a nurse could honor a physician's DNR order in an out-of-hospital circumstance. This conforms with House of Delegates Policy 85.013 which states, "When patients have not executed advance directives, facility staff should be permitted to follow physician orders for patient care (CHSO Rep. 3-A-02)." However, the Texas Legislature struck a political compromise with disability advocates and Texas Right-to-Life, and a physician DNR order is now expressly not binding upon EMS personnel. [See, Texas Health & Safety Code §166.102(b)] An out-of-hospital DNR executed by the patient is necessary to withhold life sustaining care delivered by EMS personnel. Otherwise, Texas law presumes consent to treat in an emergency. Thus, to institute a POLST in Texas will require statutory change.

Comparison of POLST with Texas OOH-DNR
The Texas Out-of-Hospital Do-Not-Resuscitate (OOH-DNR) and Oregon POLST forms are single sheet forms. Both forms are applicable only in out of-hospital-situations (the Oregon board rule mentioned previously refers to EMTs and First Responders only, not hospital emergency rooms). Both forms can be executed by non-written communication of the patient. The POLST form states there has been a discussion of end-of-life care and the Texas OOH-DNR form permits attending physicians and witnesses to sign the document when the patient orally requests a DNR.

However, the two documents have many differences. The most significant difference between the forms is that the POLST form is a physician order, while the OOH-DNR form is primarily a direct patient expression of consent (or refusal to consent) to certain care. A Texas physician then directs other health care professionals to comply with the patient order.

The POLST form is simple and permits the physician to order that wide range of care be withheld. The OOH-DNR addresses only the refusal of CPR, transcutaneous cardiac pacing, defibrillation, advanced airway management, and artificial ventilation. The OOH-DNR also is fairly complex, requiring multiple signatures.

The POLST can apply to any patient. OOH-DNRs are limited with regard to children and can be executed only when the child has a terminal or irreversible condition.

As POLST has been instituted without supporting statutory provision, it does not provide protections to physicians.  Texas OOH-DNR law has limitations and protections from liability for withholding care in compliance with a OOH-DNR. Texas OOH-DNR law also protects physicians (and other professionals) from liability for failing to effectuate an OOH-DNR when he or she has no knowledge of the existence of the executed form. The Texas Medical Board may not discipline a physician for complying with an OOH-DNR.

Finally, to be valid, the patient must have the POLST form with them when EMS personnel arrive. In Texas, if a patient is wearing a DNR bracelet, the existence of a valid OOH-DNR can be presumed by EMS personnel. This complies with current TMA House of Delegates policy which states:

85.004  Natural Death Act Directive : The Texas Medical Association endorses the concept of easy and uniform identification of patients with out-of-hospital directives (Board of Councilors, p 29, I-93; reaffirmed Board of Councilors, p 105, A-94; amended BOC Rep. 3-A-04).

Recommendation : That the Texas Medical Association continue to research improvements to the end-of-life form, including reviewing Physician Order for Life Sustaining Treatment and other forms, and develop consensus with other stakeholders on the use of a standard form for physicians to convey orders on life sustaining care.





TMA House of Delegates: TexMed 2006

Last Updated On

June 24, 2010

Originally Published On

March 23, 2010

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