POLST Post Test
1. How do POLST forms differ from Pennsylvania advance directives?
a.) POLST must be updated every three months
b.) POLST acts as a medical order
c.) POLST requires two professionals’ signatures
d.) Advance directives must be notarized
POLST differs from PA advance directives in that it acts as an actionable medical order. Advance
directives state preferences and values, but are used only to guide decision making after further
interpretation. The POLST form may be updated if care preferences change, but it does not expire.
POLST form requires the signature of one of the following: MD, PA, CRNP. Advance Directives do
not need to be notarized in PA.
Information on this can be found in: An Overview: Advance Directives and POLST
SLIDE: What is POLST
2.
What population is the POLST form recommended for?
a.) All adults over 18 years old
b.) All adults over 65 years old
c.) Anyone with advanced or serious illness
d.) Only seriously ill adults over 65 years old
POLST is recommended anyone with advanced illness, a serious health condition, medical frailty or
someone of advanced age and wishing to further define their preferences for care.
Information can be found in: An Overview: Advance Directives and POLST
SLIDE: Differences between POLST and Advance Directives
SLIDE: Who Would Benefit From a POLST
Information also available in POLST FAQs and Guidance for Healthcare Providers
3. Who facilitates completion of the POLST form?
a.) Patients
b.) Patients’ family members
c.) Physicians only
d.) Healthcare professionals
POLST form completion is facilitated by a healthcare professional who is skilled and knowledgeable
in directing end of life planning conversations and the POLST program. Ideally, facilitators should
have completed formal standardized education pertaining to POLST. While the form requires the
signature of a physician, CRNP, or PA, completion of the form can be facilitated by RNs, social
workers, chaplains, and other healthcare professionals.
Information on this can be found: An Overview: Advance Directives and POLST
SLIDE: POLST, Who fills it out?
SLIDE: Differences between POLST and Advance Directives
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POLST Post Test
4. In Pennsylvania, a POLST form that has been signed by a physician assistant requires a physician
co-signature within how many days?
a.) 1 day
b.) 3 days
c.) 7 days
d.) 10 days
Physician assistant signatures must be co-signed within 10 days by a MD to make form valid.
Information on this can be found: An Overview: Advance Directives and POLST
SLIDE: Requirements to Make the Form Valid
Information also available in POLST Guidance for Healthcare Professionals
5. Which section of the form must be completed in order for the form to be valid?
a.) Section A: Resuscitation Orders
b.) Section B: Medical Interventions
c.) Section C: Antibiotics
d.) Section D: Artificially Administered Hydration/Nutrition
Minimum requirements for a POLST include patient name, resuscitation orders (Section A) and
signature of a physician, physician assistant or nurse practitioner. Other sections may be left blank if
patient’s choice is not to complete.
Information on this can be found in POLST Guidance for Healthcare Providers
6. If a patient changes his/her treatment goals and would like to change the POLST form, how should
the outdated form be handled?
a.) Throw it away
b.) Draw an “X” over the entire form on both sides
c.) Draw a line through Sections A through E, write “VOID” across the form, and sign and date
d.) Write “VOID” in the top right corner, sign and date
POLST forms can be revoked if they become invalid or are replaced by an updated version. To do
this, draw a line through sections A through E of the invalid POLST, write ‘VOID” in large letters
across the form, and sign and date the form.
Information on this can be found at on the back of the POLST Form and POLST FAQs
Information also can be found: An Overview: Advance Directives and POLST
SLIDE: Revocation of a POLST Form
7. If the patient cannot speak for himself/herself, who is in the first order to make medical
decisions?
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POLST Post Test
a.) Appointed healthcare agent
b.) Family member
c.) Doctor
d.) Health Care Representative
An appointed health care agent is someone chosen by the patient to make health care decisions on
their behalf if they are unable to communicate their wishes or choose to activate their health care
agent. Another name is a healthcare power of attorney (HCPOA). Health care representatives are
individuals able to make some decisions for patients who are incompetent/incapacitated when
there is no HCPOA/ agent named or one willing/able to act on the patient’s behalf.
Information also can be found: An Overview: Advance Directives and POLST
SLIDE: Decision Makers
SLIDE: Quick Start Guide: Who’s on First?
8. When should the POLST form be reviewed?
a.) When the patient changes location
b.) When there is a change in his/her condition
c.) When new prognosis information arises
d.) All of the above
POLST forms should be reviewed in all of the above situations.
Information on this topic can be found: POLST FAQ’s “How and when does one review and update a
POLST form?” Information also available on back of POLST form.
9. Suppose a 78 year-old female stage III cancer patient has been non-responsive in a hospital for the
past several days. The doctor has just informed the patient’s family that her cancer has spread
and it is now at the stage IV level. Her current POLST form which she signed states “Full
Treatment.”
The husband, her health care power of attorney, would like to revoke this order. Two of three
daughters disagree. Can the husband revoke the POLST form?
a.) No, since he did not sign the POLST form
b.) No, since he is not the health care representative
c.) Yes, but only if all the daughters agree
d.) Yes, since he is the designated agent
A health care AGENT is an individual appointed in a Health Care Power of Attorney document by a
person while they have capacity to make medical decisions. Health care AGENTS have authority to
make decisions on a patient’s behalf if the patient is incapacitated. A health care REPRESENTATIVE
includes someone a patient appoints to make decisions on their behalf. If the patient has not
appointed a REPRESENTATIVE verbally, the law in PA gives priority in an outlined order. If a health
care AGENT has been named, this person can make decisions on the patient’s behalf independently.
Information on this topic can be found: An Overview: Advance Directives and POLST
SLIDE: Health Care Power of Attorney to start of POLST.
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Of specific value, Quick Start Guide to
Health Care Decision Making
10. The POLST form replaces an advance health care directive document.
TRUE
FALSE
The POLST form complements an advance health care directive document.
Information on this topic can be found: Advance Directives, Advance Care Planning, and POLST
SLIDE: 23 – 24
Information also available: POLST FAQ’s: “Is POLST an advance directive?” and “Is an advance
directive required in order to have a POLST?”
11. Photocopies and faxes of POLST forms are valid.
TRUE
FALSE
Use of the original POLST form is strongly encouraged, though photocopies and faxes of signed
POLST forms should be respected where necessary.
Information on this topic can be found on the back of the POLST form and POLST FAQ, “Can a copy
of the POLST form, rather than the original, accompany a transferring patient”.
12. The POLST form is mandatory for people 65 years and older with frailty
and/or a serious condition.
TRUE
FALSE
POLST is a voluntary process.
It is recommended for seriously ill patients of any age with advanced or serious illness, medical
frailty or anyone of advance age who wishes to further define their preferences for care.
Information on this topic can be found: An Overview: Advance Directives and POLST
SLIDE: What is POLST
Advance Care Planning Continuum
Information also available: POLST Guidance for Health Care Professionals
13. Only the patient may revoke his/her POLST form.
TRUE
FALSE
A patient with medical decision making capacity may revoke a POLST Form. It may also be revoked
by the health care agent, guardian, or health care representative if they have signed the POLST
form.
Information on this topic can be found: An Overview: Advance Directives and POLST
SLIDE: Who is the Pennsylvania Decision Maker: Power to revoke a POLST
14. If any section is left blank on the POLST form, the highest level of
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treatment must be provided.
TRUE
FALSE
If any section of the POLST is left unmarked, the highest level of treatment must be provided. In this
situation, it is also useful to review other advance health care directive documents, which may also
reflect patient wishes.
Information on this topic can be found: An Overview: Advance Directives and POLST
SLIDE: Pennsylvania Form
15. If a patient’s choice in Section A is CPR, the choice in Section B can be
either “Limited Additional Interventions” or “Full Treatment”.
TRUE
FALSE
An individual who chooses “Attempt resuscitation/CPR” in section A must be willing to have
Advanced Cardiac Life Support (ACLS) guidelines followed, which usually includes intubation and
care in the ICU. If a patient chooses CPR in section A, the choice in section B may only be “Full
Treatment”.
Information on this topic can be found: An Overview: Advance Directives and POLST
SLIDE: Diagram of POLST Medical Interventions
Information also available: POLST Guidance for Healthcare Professionals, Page 10
16. A hospitalized patient who wishes to receive full treatment for his
illness, can choose DNR for the POLST form.
TRUE
FALSE
“Do Not Attempt Resuscitation/ DNR” may be chosen with any of the medical interventions in
Section B. Such desired interventions would be followed if the patient has a pulse and/or is
breathing.
Information on this topic can be found: An Overview: Advance Directives and POLST
SLIDE: Diagram of POLST Medical Interventions
Information also available: POLST Guidance for Healthcare Professionals, Pager 10
17. According to Act 169, it is assumed a patient would want artificial
nutrition and hydration, unless specifically stated otherwise in writing.
TRUE
FALSE
According to PA Act 169, assume the patient would want artificial nutrition and hydration unless
specifically stated in writing. Overcome presumption only if patient clearly expressed wishes to the
contrary or it is clear from patient’s preferences and values that patient would not want it.
Information on this topic can be found: Act 169: A Summary, Artificial nutrition and hydration
18. A Health Care Representative is designated by someone in a form
called a Health Care Power of Attorney.
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TRUE
FALSE
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POLST Post Test
Health Care AGENTS are designated in Health Care Power of Attorney Documents. A health care
REPRESENTATIVE includes someone a patient appoints to make decisions on their behalf. If the
patient has not appointed a REPRESENTATIVE verbally, the law in PA gives priority in an outlined
order
Information on this topic can be found: An Overview: Advance Directives and POLST
SLIDE: Health Care Power of Attorney to start of POLST. Of specific value, Quick Start Guide to
Health Care Decision Making
19. The powers of a health care agent and a health care representative to
decline health care necessary to preserve life in a patient who is not in an
end stage medical condition or permanently unconscious are not the same. TRUE FALSE
A health care REPRESENTATIVE may not decline health care necessary to preserve life unless the
patient is in end stage medical condition or is permanently unconscious.
Information on this topic can be found: Act 169: A Summary
Information also available: An Overview: Advance Directives and POLST
SLIDE: End-Stage Medical Condition, Permanently Unconscious
20. The CPR survival rate of those with chronic illness averages less than 5%.
TRUE FALSE
Chronic illness, more than age, determines CPR survival rates. The average survival rate in
individuals with chronic illness is less than 5%. With advanced chronic illness, survival rates are often
less than 1%.
Information on this topic can be found: An Overview: Advance Directives and POLST
SLIDE: Section A: Cardiopulmonary Resuscitation
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