A comprehensive guide for leaders navigating the intersection of advance directive management, emerging technology, and ethical care delivery
This is the moment every clinician dreads. Picture this:
It’s a Tuesday afternoon. A resident arrives at your facility after a hospital discharge, and your admissions team needs to understand their end-of-life treatment preferences right now. Not tomorrow. Not after a chart review. Now.
The discharge paperwork mentions a POLST. But when your team goes looking for it? Nothing. The family swears one was completed last year. The hospital says check the EHR. The EHR has a scanned document from 2022 that may or may not still be valid. And while everyone is pointing fingers and shuffling papers, real clinical decisions are waiting.
If you’ve worked in post-acute or long-term care for any length of time, this story probably sounds painfully familiar. It happens every single day in facilities across the country, and it points to one of the most overlooked documentation challenges in our entire industry. We call it the “POLST workflow gap”. And it’s long overdue for a serious conversation. Provider Orders for Life-Sustaining Treatment (POLST) forms were created with a beautifully simple idea: one portable document that captures a patient’s wishes and follows them wherever they go. One form. Every setting. No confusion.
That was the vision. The reality looks nothing like it.
Depending on where you operate, POLST forms go by different names (POLST, POST, MOLST, COLST, MOST). Some states mandate registries. Others have no formal program. And a handful of states still don’t have an approved form at all. Now layer on the fact that this single document can exist in half a dozen places at once: a bright pink form tucked into a bedside chart, a scanned image buried in the EHR, a state registry entry, a medical alert bracelet, a paper copy in a family member’s glove compartment, and a record in third-party software your facility doesn’t use.
That’s not a system. That’s chaos with good intentions. The POLST doesn’t have a home. It has six of them, and none of them talk to each other. Most EHRs, even ones within the same health system, still can’t share data reliably. We hear “interoperability” in conference keynotes and vendor pitches, but on the ground? Transferring a simple advance directive from one system to another still feels like passing a note through a wall. The consequences are real. Consider a scenario like this: a women completed a POLST directing full code while living independently. Later, after a small stroke, she went into cardiac arrest at the hospital. The team did not attempt resuscitation. They believed she was DNR. She wasn’t. The systems that held her information couldn’t talk to each other, and the system failed her.
Interoperability is a team sport. No single organization, vendor, or payer will fix this alone. It takes shared language, shared expectations, and shared accountability. We’re not there yet, but the cost of waiting is measured in moments like hers.
Why Putting It in the EHR Isn’t the Whole Answer
Here’s where we push back on the conventional wisdom a little.
The instinct in healthcare right now is to digitize everything. Get it into the EHR. Make it electronic. Problem solved. And yes, absolutely, your EHR should contain the POLST. Everyone should be doing that already. But a POLST that lives only in your EHR has a critical blind spot. It fails the portability test. When paramedics arrive at your facility at two in the morning because a resident is in cardiac distress, they are not pulling up your electronic health record. They’re looking for a physical form. They’re checking for a medical bracelet. They need information they can see and act on immediately.
This is why we advocate for what we’ve started calling the dual-existence strategy. The POLST has to live in two worlds simultaneously. It needs to be in your digital systems for clinical workflows, care planning, and transitions. And it needs to be physically present, visible, and accessible for the moments when technology isn’t in the room. That bright pink form? It’s not a relic of the paper era. It’s a design feature. It exists because in an emergency, color and placement save time. Don’t retire it just because you’ve gone digital. Instead, build a workflow that keeps both versions current, synchronized, and accessible.
Different care situations demand different access points. A robust POLST program respects that reality instead of pretending technology has eliminated it.
The Regulatory Landscape Is Shifting Fast
If the clinical argument for fixing POLST workflows isn’t enough, the regulatory environment is about to force the conversation. Recently, federal health officials launched the Digital Health Ecosystem initiative with a new CMS Interoperability Framework that changes the game for data sharing. On the standards front, ONC’s HTI-1 Final Rule adopted USCDI v3 as the new baseline, requiring certified health IT to support FHIR US Core profiles by January 1, 2026. The infrastructure for better advance directive sharing is being built. This isn’t aspirational language anymore. For POLST specifically, some genuinely exciting progress is happening. States are beginning to make POLST forms available nationwide. For the first time, clinicians in participating EHR systems can pull up a state’s POLST as if it were native to their own workflow. That’s a big deal. The question is whether your organization is ready to plug into it.
What Blockchain and AI Could Actually Do for POLST – Let’s address emerging technology, but do it honestly.
Blockchain gets thrown around a lot in healthcare conversations, sometimes with more hype than substance. But for POLST, there’s a genuinely compelling use case. At its core, blockchain is a digital ledger that records transactions chronologically across a distributed network. Nobody can quietly alter a record without everyone knowing. That tamper-resistance is exactly what you want for a document where version control is literally a life-or-death issue. Imagine a world where every POLST update gets recorded on an immutable ledger. Every facility, every provider, every EMS team can verify they’re looking at the current version. No more guessing. No more “I thought this was the latest one.” Blockchain also creates a clear audit trail for consent and access, which helps with both HIPAA compliance and building patient trust. AI brings a different set of strengths to the table. Once you have reliable, organized data (and that’s a big “once”), artificial intelligence can do things humans simply can’t do at scale. It can flag discrepancies between advance directives across different care settings. It can alert a clinician when a diagnosis change might warrant a POLST conversation. It can help reconcile conflicting versions and surface the right information at the right moment.
A recent CHIME survey found a third of respondents said AI-driven interoperability is crucial for improving data sharing and care coordination. Nearly half of CIOs surveyed said they want AI capabilities natively embedded in their EHR, not bolted on as afterthoughts. The combination of blockchain’s security and AI’s intelligence is genuinely promising. But we need to talk about the fine print.
The Hurdles – Blockchain has real scalability problems. It’s energy intensive. Integrating it with legacy hospital systems is complex, expensive, and slow. For PAC/LTC settings specifically, where EHR maturity often lags behind acute care, these challenges are even more pronounced. AI, meanwhile, faces a trust problem. Clinicians need to believe the technology is giving them accurate information before they’ll rely on it for something as consequential as end-of-life care. That trust has to be earned over time, not assumed. And here’s the foundational issue that doesn’t get said enough: AI can only learn from data it can access. If your systems aren’t interoperable, if your POLST data is trapped in scanned PDFs and disconnected software, the smartest algorithm in the world can’t help you. Interoperability isn’t a nice-to-have that you’ll get to eventually. It’s the prerequisite for everything else.
Aging services providers tend to move more slowly through advanced EHR maturity stages, even when baseline adoption is solid. That’s not a criticism. It’s a reality driven by resource constraints, competing priorities, and a workforce that’s already stretched thin. But it does mean that PAC/LTC leaders need to start planning strategically now, even if full implementation is years away.
None of This Matters Without Patient-Centered Values
We’ve spent a lot of time talking about technology. Let’s zoom back out.
Every POLST form represents a human being who sat down, probably during one of the most difficult conversations of their life, and said: “This is what I want. This is what I don’t want. Please honor that.” Advance directives are fundamentally about autonomy. They exist because we believe people have the right to make informed decisions about their own care, even when they can no longer speak for themselves. The Belmont Report gives us a clear ethical framework for evaluating any technology we introduce into this space. Respect for Persons: does it honor patient autonomy and protect vulnerable individuals? Beneficence: does it maximize benefits and minimize harms? Justice: are the burdens and benefits distributed fairly?
Before your organization adopts any new POLST technology, put it through that filter. If a platform makes documentation more efficient but doesn’t actually improve the patient’s ability to have their wishes honored, you’ve optimized the wrong thing.
And let’s not forget what a POLST actually is. It’s the outcome of a conversation. A real, human, often emotional conversation between a patient, their family, and their care team about what matters most. Healthcare professionals play an irreplaceable role in guiding those discussions, helping patients think through their values, their fears, their hopes. A blockchain-secured POLST that was completed without a meaningful conversation is just a very well-protected piece of paper. The technology should support the dialogue, not skip over it.
As we move toward more sophisticated digital solutions for advance directive management, who gets left behind?
The barriers are real. Older adults with limited technology experience. Patients with cognitive impairment. Families navigating low-income situations. Facilities in rural areas with minimal IT infrastructure. If the future of POLST management requires a smartphone, a broadband connection, and digital literacy, we’ve just created a two-tiered system where patient autonomy depends on socioeconomic status.
That’s unacceptable.
Any technology solution worth implementing must maintain strong offline and paper-based backup systems. It has to work in a facility with three computers and spotty Wi-Fi just as well as it works in a system with a dedicated IT department. And, leaders need to keep asking a simple but powerful question: does this serve our most vulnerable residents as well as it serves our most connected ones?
There’s also a thorny issue around surrogate decision-makers. When patients lack decisional capacity, proxy decision-makers often interact with documentation systems on their behalf. Clear protocols must govern who can access POLST information, who can modify it, how permissions are verified, and how every change is tracked. This isn’t just good practice. It’s an ethical obligation.
People change their minds. It happens all the time, and it’s completely natural. Someone completes a POLST during a moment of relative health, and then their circumstances shift. They experience a new diagnosis. They adapt to a disability they once feared. They watch a loved one go through something that changes their perspective entirely. An old POLST may no longer reflect what a patient actually wants today. That’s not a technology failure. It’s a human reality. And, it’s exactly why ongoing conversations between patients, their families, and their care teams matter so much more than any single document.
The POLST form gets reviewed more frequently than a standard advance directive precisely because wishes can evolve as a disease progresses. But that review only happens when a real person sits down with a real patient and asks: “Is this still what you want?”
No algorithm does that. No blockchain does that. No interoperability standard does that. Technology can remind you it’s time for the conversation. It can surface the right information. It can make sure the updated document gets where it needs to go. But the conversation itself? That belongs to the humans in the room.
So Where Do You Start?
If you’ve read this far, you’re probably thinking: “Okay, I get it. This is broken. But what do I actually do about it on Monday morning?” Fair question. Here’s how we think about it across three time horizons.
Right now, get your arms around your current state. Walk the workflow from the moment a POLST enters your facility to the moment it leaves with a discharged or transferred resident. Where does it come in? How does it get captured? Who checks if it’s current? Where does it go during a transition? You will find gaps. Everyone does. Once you see them, you can start closing them.
Establish what your team considers the single source of truth. National POLST guidance recommends identifying one primary source, the source that always has the most recent version, and building every other process around keeping it current. Decide what that source is for your organization and make sure every staff member knows.
Over the next six to eighteen months, focus on getting your data house in order. If your EHR captures POLST as a scanned image, that’s a dead end for interoperability. Work toward discrete, structured data that future systems can actually use. Keep an eye on what your state is doing with POLST registries and EHR integration. Get involved with vendor user groups and professional associations. And bring residents and family members into your technology evaluation process. Their perspective will keep you grounded.
Looking further out, start thinking about what a truly integrated patient record could mean for advance directive management. When AI capabilities mature inside your EHR, they could surface POLST information automatically, flag conflicts, and prompt timely review conversations. But none of that works without the interoperability foundation you’re building now.
The facilities that come out ahead over the next three years won’t be the ones with the flashiest technology. They’ll be the ones that turned interoperability from a buzzword into a daily workflow, built systems that kept clinicians informed and patients protected, and never lost sight of why this work matters in the first place.
The Only Question That Really Matters
At its core, POLST is about a promise. A promise that when someone can no longer speak for themselves, their voice will still be heard. That their wishes will be honored, not lost in a fax machine or buried in a software system nobody can access.
A POLST is a medical order. A legal document. A communication tool. An ethical commitment. No single piece of technology can carry all of that weight. The organizations that get POLST management right will be the ones that build workflows honoring every one of those dimensions, keeping the document alive both inside and outside the EHR ecosystem.
Here’s the question that really matters: it’s not whether blockchain or AI can make POLST management smoother. It’s whether the systems we choose, the tech we bring in, and the workflows we create actually help us honor what we promised. When someone is facing the most vulnerable chapter of their life, that promise is everything. It deserves every tool we can bring to bear.
The intersection of technology, documentation workflows, and patient-centered end-of-life care raises questions that look different in every organization.
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