advance-directive-vs-polst

# Advance Directive vs. POLST Comparison

Compares advance directives (legal planning documents) with POLST/MOLST forms (clinician-signed medical orders). These occupy different legal and clinical lanes — confusing them creates dangerous gaps in emergency care.

## Quick Start

Gather before drafting (skip if user says "use defaults"):

1. **State(s) of residence** — required before any jurisdiction-specific claim
2. **Existing documents** — current advance directive, POLST/MOLST, or neither
3. **Health status** — healthy / chronic illness / serious illness / advanced frailty / terminal
4. **Care setting** — home, hospital, SNF, assisted living
5. **Named healthcare agent** — appointed? successors?
6. **Primary question** — e.g., "Which form wins in an emergency?"

Defaults if no response: general comparison, no state-specific claims, healthy adult context, educational memo format.

## Core Distinction Table

| Feature | Advance Directive | POLST / MOLST |
|---|---|---|
| **Nature** | Legal planning document | Clinician-signed medical order |
| **Purpose** | Appoints agent; expresses values | Translates preferences into actionable orders |
| **Who signs** | Principal (+ witnesses/notary per state) | Clinician + patient or rep |
| **Who it instructs** | Agents, families, downstream clinicians | EMS, hospitals, facilities — immediately actionable |
| **Scope** | Broad: values, agent authority, end-of-life wishes | Specific: CPR, hospitalization, ventilation, nutrition |
| **Appropriate for** | All competent adults | Serious illness, advanced frailty, limited life expectancy |
| **EMS usability** | Generally not actionable at scene | Yes — designed for field portability |
| **Clinician signature?** | No | **Yes — invalid without it** |

## Emergency Precedence

**POLST takes practical precedence in the field.** EMS looks for medical orders, not legal documents.

- POLST "Do Not Attempt Resuscitation" → EMS generally follows it
- Advance directive alone → EMS may default to full treatment
- **At hospital with agent present**: agent has legal authority (from directive) to request physician revoke/modify POLST
- **Conscious patient with capacity**: contemporaneous wishes control regardless of documents

> Never promise "EMS will always follow" any form. Availability, local protocol, validity, and state registry participation determine what gets followed.

## Clinical Appropriateness

POLST is **not** for healthy adults. Use the "Surprise Question": *Would you be surprised if this patient died in the next year?* If yes → POLST is premature.

**Nursing home warning**: Facilities sometimes present POLST as routine intake paperwork. Clients should not sign without a goals-of-care discussion with their physician about actual prognosis.

## Document Coordination

Advance directive = values framework + agent authority. POLST = current clinical goals as orders. They must be consistent.

- **Conflict** (directive says "do everything," POLST says "DNR"): clinicians often follow the most current, most specific, properly signed order — state-dependent. Treat inconsistency as urgent.
- **Agent role**: can participate in POLST discussions and request physician updates, but **cannot unilaterally revoke** a POLST. Modification requires clinician to cancel and reissue.
- **Access**: directive accessible at hospital for agent authority proof; POLST physically accessible to EMS (refrigerator, chart front, state registry).

## Deliverable

Draft a memo or client handout covering:

- Plain-language definitions of each document
- Who signs each; why clinician signature is essential for POLST
- Emergency scenario (practical, scenario-based)
- Whether POLST is appropriate given client's health status
- How to ensure consistency between documents
- Next steps: update directive / initiate POLST conversation with physician / void outdated copies

Use analogy: advance directive = "constitution," POLST = "executive order."

## Post-Draft Checks

Ask after delivering:

1. Does this answer your specific question?
2. Do you have both documents — are they consistent?
3. Want help drafting or updating either document? (separate skill)
4. Any out-of-state care scenarios to address?

## State Terminology

Adapt to the state's label before finalizing:

| Acronym | States |
|---|---|
| POLST | CA, OR, WA, others |
| MOLST | NY, MD |
| MOST | NC, SC |
| POST | ID, TN, UT, WV, others |
| TPOPP | MN |
| Out-of-Hospital DNR only | FL, TX (limited scope) |

Verify via the National POLST program directory before asserting any state's form name.

## Guardrails

**Scope**: This skill explains and compares — does not draft documents, determine capacity, or resolve validity disputes.

**Anti-hallucination**:
- No state-specific claims without verified jurisdiction
- No invented statutory citations or case names
- No assertions about POLST signer eligibility without verification — mark `[VERIFY]`
- No medical advice (e.g., which POLST boxes to check)
- No promises any document "will always be honored"

**Quality checklist**:
- [ ] Core distinction table accurate
- [ ] Emergency precedence scenario-based
- [ ] Clinical appropriateness assessed for client's health
- [ ] POLST form name matches state terminology
- [ ] Agent role and limitations explained
- [ ] Document consistency addressed
- [ ] Citations verified or marked `[VERIFY]`
- [ ] Next steps provided
- [ ] Disclaimer included

**Required disclaimer**: *This is general legal information, not legal advice. Review with a licensed attorney before use in any client matter and with a licensed clinician before any medical decisions are implemented.*