Advance directive vs POLST: what families should know

If someone you love has a serious illness, you may hear two terms come up again and again: advance directive and POLST. They sound similar, and both are about end-of-life wishes, so it is easy to assume they are the same thing. They are not, and knowing the difference can help your family avoid confusion at a stressful moment.

In short, an advance directive is a legal document a person fills out to describe their wishes and, usually, to name someone who can speak for them. A POLST is a set of medical orders, signed with a health care professional, that tells emergency and medical teams what to do right now. This article walks through each one in plain terms. It is general information, not medical or legal advice, and the rules differ from state to state.

An advance directive is a document any adult can complete, whether they are healthy or ill. It usually has two parts. One part names a health care agent, sometimes called a health care proxy or medical power of attorney, who can make decisions if the person cannot speak for themselves. The other part, often called a living will, describes the kinds of care the person would or would not want.

Because it is written ahead of time and in general terms, an advance directive is a guide for the people making decisions. It works best when the person has also talked with their agent about what matters to them, not just which boxes they checked. Each state has its own forms and signing rules, such as witnesses or a notary, so it is worth using your state's version.

POLST stands for Portable Medical Orders, or in many places Physician Orders for Life-Sustaining Treatment. It is meant for people who are seriously ill or very frail, the kind of situation where a doctor would not be surprised if the person died within the next year. It is not intended for healthy adults.

A POLST is filled out during a conversation between the person (or their decision-maker) and a health care professional. It turns the person's current wishes into specific medical orders, for example whether to attempt CPR and how much treatment they want in an emergency. Both the clinician and the person or their decision-maker sign it. Completing one is voluntary.

The name varies. Depending on your state, you may see it called POLST, MOLST, POST, MOST or something similar. If you are not sure what your state uses, ask your doctor or hospice team.

Who it is for: an advance directive is recommended for every adult. A POLST is for people with a serious illness or advanced frailty.

What kind of document it is: an advance directive is a legal document that states wishes and names an agent. A POLST is a medical order that tells clinicians what to do. A POLST does not name a health care agent, which is one reason it does not replace an advance directive.

When it is used: an advance directive guides decisions over time. A POLST is designed to be followed quickly, including by emergency responders, who generally need a medical order rather than a living will to act on. Exactly how each document is honored depends on your state's laws.

For someone who is seriously ill, the two documents work together. The advance directive makes sure there is a trusted person with legal authority to speak up and that the person's values are written down. The POLST makes sure their current treatment choices are clear to anyone who responds in an emergency, at home or in a care facility.

If your loved one is on hospice, ask the team whether a POLST or your state's version is already in place. Hospice nurses and social workers often help families with these forms and can explain how they apply where you live.

A form only helps if people can find it. Keep the original POLST with the person. At home, many programs suggest a visible spot that emergency responders will see, such as near the bed or on the refrigerator. Give copies to the health care agent and make sure the doctor's office or care facility has one in the medical record.

Advance directives should also be easy to reach, not locked away in a safe deposit box. Share copies with the named agent, close family and the person's doctors. Some states run registries where documents can be filed; ask your doctor or check with your state health department.

Wishes can change as an illness changes. A POLST can be reviewed and updated at any time with a health care professional, and it is wise to look at it again after a hospital stay, a move to a new care setting or a big change in health. An advance directive can also be revised. When you make a new version, collect and replace the old copies so no one relies on outdated wishes.

These conversations are not easy. An end-of-life doula can help by sitting with your family as you talk through what matters most, helping you write down questions for the care team, and making sure the paperwork reflects the person you love. A doula does not give legal or medical advice, but can help keep the conversation calm and focused. For specific questions about your state's forms or laws, talk with the hospice team, the person's doctor or an elder law attorney.