Understanding Advance Directives and POLST Forms in Adult Family Home Care

Advance care planning is one of the most important yet sensitive responsibilities in adult family home (AFH) care. Advance directives and POLST (Physician Orders for Life-Sustaining Treatment) forms ensure that residents' healthcare wishes are known, documented, and honored — particularly during medical emergencies when residents may be unable to communicate their preferences. For AFH providers, understanding these documents, facilitating advance care planning conversations, and maintaining accessible documentation can literally mean the difference between honoring a resident's deeply held wishes and subjecting them to unwanted medical interventions.

The National Institute on Aging (NIA) reports that while the majority of Americans say they want to discuss end-of-life preferences with their families, fewer than one-third have actually completed advance directive documents. In adult family homes, where residents are often dealing with serious chronic conditions, ensuring that advance care planning is completed is both a legal obligation and an ethical imperative.

Types of Advance Directive Documents

Living Wills

A living will is a written document that specifies an individual's preferences for medical treatment in situations where they cannot communicate their wishes. Living wills typically address preferences regarding cardiopulmonary resuscitation (CPR), mechanical ventilation, artificial nutrition and hydration through feeding tubes, dialysis, blood transfusions, organ and tissue donation, palliative and comfort care preferences, and the circumstances under which the individual would want life-sustaining treatment withheld or withdrawn.

The American Bar Association (ABA) provides information on state-specific living will requirements, as the legal requirements and formats vary by state.

Healthcare Power of Attorney

A healthcare power of attorney, also called a healthcare proxy or durable power of attorney for healthcare, designates another person to make medical decisions on behalf of the individual when they are unable to do so themselves. This document is considered more flexible and comprehensive than a living will because the designated agent can respond to unanticipated medical situations that may not have been addressed in a living will.

The U.S. Department of Health and Human Services provides resources on understanding healthcare power of attorney documents and their legal implications.

Do Not Resuscitate Orders

A Do Not Resuscitate (DNR) order is a medical order signed by a physician that instructs healthcare providers not to perform cardiopulmonary resuscitation if the patient's heart stops beating or if they stop breathing. DNR orders are distinct from advance directives in that they are physician orders with immediate legal authority, while advance directives express patient wishes that guide medical decision-making.

AFH providers must understand that a DNR order only addresses CPR — it does not affect any other medical treatment. Residents with DNR orders should still receive all other appropriate medical care, comfort measures, and symptom management.

Understanding POLST Forms

What POLST Is

POLST, known by various names in different states including MOLST, MOST, POST, and COLST, is a standardized medical order form that translates a patient's treatment preferences into actionable medical orders. Unlike advance directives which express wishes, POLST forms are actual physician orders that must be followed by healthcare providers including emergency medical services.

The National POLST organization coordinates POLST programs across the United States and provides state-specific information on POLST implementation and requirements.

What POLST Addresses

POLST forms typically address several key treatment decisions including CPR preferences with options for full resuscitation or DNR, medical interventions with options ranging from full treatment to comfort-focused treatment only, artificially administered nutrition with preferences regarding feeding tubes, and in some states antibiotics and other specific treatment categories.

Who Should Have a POLST

POLST forms are intended for individuals with serious illness, frailty, or advanced age who may face medical emergencies where treatment decisions need to be made quickly. The American Geriatrics Society (AGS) recommends POLST completion for individuals with progressive chronic illness, those whose death within one to two years would not be surprising, and residents of long-term care facilities. For many AFH residents, POLST completion is appropriate and important.

POLST vs. Advance Directives

POLST and advance directives serve complementary but distinct purposes. Advance directives express wishes and are created by the individual, while POLST forms are medical orders created through a conversation between the patient or their representative and a qualified healthcare provider. Advance directives apply broadly across all healthcare situations, while POLST addresses specific emergency treatment decisions. Advance directives require interpretation before they can guide treatment, while POLST orders are immediately actionable.

Both documents should be maintained in the resident's care record, and they should be consistent with each other. When discrepancies exist, the most recently completed document generally takes precedence.

Facilitating Advance Care Planning Conversations

Creating a Supportive Environment

Advance care planning conversations require sensitivity, time, and a supportive environment. The Conversation Project provides excellent resources and conversation guides that AFH providers can use to facilitate these discussions. Key principles for effective conversations include choosing a calm, private setting free from interruptions, approaching the topic as an ongoing conversation rather than a one-time event, using open-ended questions that invite reflection and sharing, respecting cultural, religious, and personal values that influence decisions, avoiding medical jargon and using clear and compassionate language, allowing adequate time for questions and emotional processing, and including family members and the healthcare power of attorney in conversations when the resident wishes.

Questions to Guide Discussion

Helpful questions for advance care planning conversations include what does quality of life mean to you, are there medical treatments you would definitely want or definitely not want, if you could not speak for yourself who would you want to make decisions for you, have you had experiences with others' end-of-life care that influenced your thinking, what are your biggest fears about medical treatment at end of life, and how important is it to you to be at home versus in a hospital if you become very ill.

The Five Wishes document provides a user-friendly format that addresses both medical and personal wishes for end-of-life care in language that is accessible to non-medical individuals.

Working with Families

Family dynamics can significantly influence advance care planning. AFH providers should recognize that family members may have different opinions about the resident's care, cultural expectations regarding family decision-making vary widely, some families may be uncomfortable discussing end-of-life topics, the resident's wishes should remain central even when family members disagree, and involving the resident's physician can help mediate difficult family discussions.

The Family Caregiver Alliance provides resources on navigating family dynamics during advance care planning that AFH providers and families may find helpful.

Documentation and Accessibility

Maintaining Current Documents

AFH providers have a responsibility to ensure that advance directive documents are current, accessible, and properly maintained. Documentation management best practices include obtaining copies of all advance directive documents at admission, storing documents in a consistent, easily accessible location in the resident's care record, ensuring all staff know where to find advance directive documents, maintaining copies of POLST forms in a visible and standardized location, providing copies to emergency medical services when residents are transported, and updating documents when residents' wishes change.

When Documents Need Updating

Advance directives and POLST forms should be reviewed and updated after a significant change in health status, following a hospitalization or major medical event, when the resident expresses new preferences about treatment, when the designated healthcare agent changes, annually as part of a comprehensive care review, and whenever state law changes requirements for advance directive documents.

Electronic Documentation

Maintaining electronic copies of advance directive documents in addition to paper originals ensures accessibility and backup protection. Care management platforms like AFH Manager allow providers to store and organize advance directive documents alongside other care records, ensuring that critical documents are available when needed most.

Legal Considerations

State-Specific Requirements

Advance directive laws vary significantly by state. The National Hospice and Palliative Care Organization (NHPCO) maintains information on state-specific advance directive requirements. AFH providers must understand their state's requirements for valid advance directive execution, witness and notarization requirements, healthcare power of attorney designation, POLST program implementation and form requirements, and mandatory reporting or documentation obligations.

Capacity and Decision-Making

A resident must have decision-making capacity to execute or change advance directive documents. The American Medical Association (AMA) defines capacity as the ability to understand relevant information, appreciate the consequences of decisions, reason about treatment options, and communicate a choice. When capacity is questionable, the resident's physician should perform a formal capacity assessment.

Honoring Resident Wishes

AFH providers have a legal and ethical obligation to honor valid advance directives and POLST orders. This includes following DNR orders when cardiac or respiratory arrest occurs, implementing comfort-focused care when indicated by advance directives, contacting the designated healthcare agent when medical decisions are needed, not performing CPR when a valid DNR order exists, and communicating advance directive contents to emergency medical services during transfers.

Emergency Situations

When Emergencies Occur

Having advance directive documents readily available during emergencies is critical. AFH providers should ensure that POLST forms are immediately accessible, posted in a standardized location, all staff know the location and content of each resident's advance directives, emergency procedures incorporate advance directive review, and copies accompany residents during hospital transfers.

Communication with EMS

When calling 911 for a resident, AFH providers should immediately communicate the resident's code status and present the POLST form to arriving emergency medical personnel. In the absence of a valid POLST or DNR order, EMS personnel are generally required to attempt full resuscitation.

Training and Education

Staff Training Requirements

All AFH staff should receive training on advance directives and POLST as part of their orientation and ongoing education. Training topics should include types of advance directive documents and their purposes, location and accessibility of resident advance directive documents, how to respond to medical emergencies in accordance with advance directives, communication with EMS about resident advance directive status, recognizing when advance care planning conversations may be appropriate, and cultural sensitivity in end-of-life decision-making.

Advance care planning is a profound responsibility that honors residents' autonomy and ensures their wishes guide medical decisions. By facilitating thoughtful conversations, maintaining accessible documentation, training staff thoroughly, and coordinating with healthcare providers and families, AFH providers can ensure that every resident's voice is heard and respected in their most vulnerable moments. Care management platforms like AFH Manager support comprehensive documentation of advance directives and POLST forms, helping providers maintain the organized, accessible records that effective advance care planning demands.

Know which document guides which decision

Maintain the resident's advance directive, healthcare representative documents, POLST or other portable medical order when applicable, clinician contact, effective dates, signatures, current goals, storage location, emergency copy, transfer procedure, and review schedule. Resolve conflicts rather than choosing whichever copy is easiest to find. The AFH advance care planning guide explains resident-led discussion, authority, clinical orders, and change review.

Frequently asked questions

Is a POLST the same as an advance directive?

No. A POLST is a portable medical order for people with serious illness or frailty under applicable state processes; an advance directive communicates wishes and decision-maker information. Both require current verification.

Can family verbally change a POLST instruction?

Do not alter or disregard a current medical order based only on an informal request. Verify resident capacity and wishes, representative authority, clinician direction, and emergency requirements, and document clarification.

Where should these documents be stored?

Use secure, role-appropriate storage with immediate availability to authorized staff and emergency responders, a controlled transfer copy, version identification, and protection against outdated duplicates.

Keep current directives accessible in an emergency

Explore AFH Manager with fictional directives to test restricted storage, representative authority, emergency access, transfer packets, version review, and care-plan alignment.