TO THE EDITOR: The recent article by Feder and colleagues (1) describes an observational study started in King County, Washington, in 1998 and made reference to a specific, state-approved prehospital do-not-resuscitate (DNR) order form. Since that study began, Washington has replaced this form with the Physician Orders for Life-Sustaining Treatment (POLST) form. The accompanying editorial by Kellerman and Lynn (2) describes the value of the POLST form as an increasingly widespread standard form for seriously ill persons to document their treatment wishes as physician orders. The POLST form originated in Oregon, and research has demonstrated its effectiveness in helping patients have their preferences for end-of-life care honored, even when emergency medical services (EMS) are contacted.

Encouraged by the success of the POLST program in Oregon, the Regional Ethics Network of Eastern Washington adapted the form for use in the state of Washington. The Washington State Medical Association (WSMA) and the Washington State Department of Social and Health Services and Department of Health approved a pilot of the POLST form in 2 counties in eastern Washington in 2000. On the basis of the results of that pilot, the Washington State Department of Health replaced the previously approved prehospital DNR order form with the POLST form in 2001. Educational and promotional efforts have been ongoing: The Washington State Department of Health has been training EMS responders in all counties in the state; WSMA publications and workshops are targeting physicians, as well as providing a POLST video and tools on its Web site (www. wsma. org); and the Association of Washington Public Hospital Districts is providing sample hospital policies and procedures, training videos, and Webcasts for effective POLST form use in hospitals. These efforts are being collaborated with a statewide, broad-based, community action coalition (Washington End-of-Life Consensus Coalition). On the basis of these efforts and national studies (3), the POLST program complements available advance directives and is extremely beneficial in confidently guiding EMS treatments in the field. Greater success of these efforts in Washington and elsewhere, as described on the National POLST Paradigm Initiative Web site (www. polst. org), can apprise EMS professionals about the patient’s treatment preferences and provide the physician’s orders that are required to act on those wishes. This benefits the patient, his or her family, and the emergency responders. Feder and colleagues accurately state that these decisions are made at the EMS technician level. The POLST form provides the desired guidance for those decisions and negates the legal and risk management concerns noted by the authors. As Oregon has demonstrated, continued perseverance in education and implementation in partnership with physicians, hospitals, nursing homes, and EMS responders can help ensure that patients receive the treatments that they want and not receive the treatments that they would have refused. With the POLST form, EMS responders can provide family support and avoid unwanted and ineffective resuscitation attempts. For Annals readers, a key to successful adoption of the POLST form is the support of a local