It Isn’t Easy Being Pink: Potential Problems with POLST Paradigm Forms

Hamline Law Review 36:2 177-211, 2013

35 Pages Posted: 8 Jan 2014 Last revised: 29 Jan 2014

See all articles by Stanley Terman

Stanley Terman

Caring Advocates or Institute for Strategic Change

Date Written: August 6, 2013


The Physician Orders for Life-Sustaining Treatment (POLST) Paradigm is a national program that is becoming one of the most widely accepted ways to express patients’ end-of-life treatment preferences. At present, only five American states do NOT have an established or developing POLST program. The focal point of the POLST Paradigm is the POLST form, which sets forth the kinds of medical treatment patients will or will not receive toward the end of their lives. Many POLST forms are printed on vibrant pink paper, to draw attention to their presence in likely voluminous patient charts or medical records. More generally, the map of American states that have or are developing POLST paradigm programs on the website, is PINK.

This essay considers six potential problems associated with the use of POLST Paradigm forms: Using POLST forms (1) may not be effective; (2) may not be moral; (3) may not reflect patients’ wishes; (4) may not be constitutional (or may not be consistent with state laws); (5) may be clinically dangerous; and (6) may open the door to opportunistic abuse. At worst, using POLST forms may lead to inappropriate treatment decisions that contribute to the patient’s premature death by forgoing treatment that — if the patient still possessed capacity and could express his/her will, would have stated was wanted.

To address the word “potential”: the problems that this essay considers are not inevitable, may occur infrequently, or may occur even without the use of POLST forms. For some problems, we have only theory, anecdotes, or reports on small numbers of patients — not statistically significant data. For purposes of beginning discussions, this essay includes the author’s opinions regarding whether POLST forms, or the laws that created them, or the way these forms can be and are used, are responsible — in whole, in part, or not at all. There are important clinical roles that POLST forms may fulfill, at times uniquely; for example, they are immediately actionable physician orders that are accepted across treatment settings, which may avoid providing unwanted or non-beneficial treatment — even for patients who did not previously complete a specific and clear Living Will relevant to his/her current medical condition. So, rather than recommending that POLST forms not be used because they are “too dangerous” or “too flawed” as others have done, this author offers for readers’ consideration, specific recommendations whose goal is to lessen or avoid these potential problems.

Keywords: Physician Orders for Life-Sustaining Treatment, POLST, advance care planning, honoring patient wishes, end of life treatment, patient safety, premature dying, physician-assisted dying, POLST immoral Catholic, POLST abuse, POLST conversation patients' wishes, dangers of POLST, POLST flawed

Suggested Citation

Terman, Stanley, It Isn’t Easy Being Pink: Potential Problems with POLST Paradigm Forms (August 6, 2013). Hamline Law Review 36:2 177-211, 2013, Available at SSRN:

Stanley Terman (Contact Author)

Caring Advocates or Institute for Strategic Change ( email )

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United States
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