A 76-year-old man is brought to the hospital after having a stroke. Head CT is done in the emergency department and shows intracranial hemorrhage. Upon arrival to the ED he is verbally non-responsive and withdraws only to pain. He does not open his eyes. He is transferred to the medical ICU for further management and intubated for airway protection. During his second day in the ICU, his blood pressure is measured as 91/54 mmHg and pulse is 120/min. He is given fluids and antibiotics, but he progresses to renal failure and his mental status deteriorates. The physicians in the ICU ask the patient’s family what his wishes are for end-of-life care. His wife tells the team that she is durable power of attorney for the patient and provides appropriate documentation. She mentions that he did not have a living will, but she believes that he would want care withdrawn in this situation, and therefore asks the team to withdraw care at this point. The patient’s daughter vehemently disagrees and believes it is in the best interest of her father, the patient, to continue all care. Based on this information, what is the best course of action for the physician team?

Listen to the patient’s wife’s wishes and withdraw care

Call other family members and consult them for their opinions

Listen to the patient’s daughter’s wishes and continue all care

Compromise between the wife and daughter and withdraw the fluids and antibiotics but keep the patient intubated

Consult the hospital ethics committee and continue all care until a decision is reached

An 8-year-old boy and his 26-year-old babysitter are brought into the emergency department with severe injuries caused by a motor vehicle accident. The child is wheeled to the pediatric intensive care unit with a severe injury to his right arm, as well as other external and internal injuries. He is hemorrhaging and found to be hemodynamically unstable. He subsequently requires transfusion and surgery, and he is currently unconscious. The pediatric trauma surgeon evaluates the child’s arm and realizes it will need to be amputated at the elbow. Which of the following is the most appropriate course of action to take with regards to the amputation?

Amputate the child’s arm at the elbow joint

Obtain an emergency court order from a judge to obtain consent to amputate the child’s arm

Find the child’s parents to obtain consent to amputate the child’s arm

Wait for the child’s babysitter to recover from her injuries to obtain her consent to amputate the child’s arm

Wait for the child to gain consciousness to obtain his consent to amputate his arm

A psychiatrist receives a call from a patient who expresses thoughts of harming his ex-girlfriend. The patient describes a detailed plan to attack her at her workplace. Which of the following represents the psychiatrist's most appropriate legal obligation?

Warn the ex-girlfriend and notify law enforcement

Only notify the patient's family

Maintain patient confidentiality

A 68-year-old woman was recently diagnosed with pancreatic cancer. At what point should her physician initiate a discussion with her regarding advance directive planning?

Now that she is ill, speaking about advance directives is no longer an option

Only if her curative surgical and medical treatment fails

Only if she initiates the conversation

A 67-year-old woman is brought by ambulance from home to the emergency department after she developed weakness of her left arm and left face droop. According to her husband, she has a history of COPD, hypertension, and hyperlipidemia. She takes hydrochlorothiazide, albuterol, and atorvastatin. She is not on oxygen at home. She is an active smoker and has smoked a pack a day for 20 years. Her mother died of a heart attack at age 60 and her father died of prostate cancer at age 55. By the time the ambulance arrived, she was having difficulty speaking. Once in the emergency department, she is no longer responsive. Her blood pressure is 125/85 mm Hg, the temperature is 37.2°C (99°F), the heart rate is 77/min, and her breathing is irregular, and she is taking progressively deeper inspirations interrupted with periods of apnea. Of the following, what is the next best step?

Start tissue plasminogen activator (tPA)

Obtain non-contrast enhanced CT of brain

A 72-year-old woman is brought to the emergency department by ambulance after an unexpected fall at home 1 hour ago. She was resuscitated at the scene by paramedics before being transferred to the hospital. She has a history of ischemic heart disease and type 2 diabetes mellitus. She has not taken any sedative medications. Her GCS is 6. She is connected to a mechanical ventilator. Her medical records show that she signed a living will 5 years ago, which indicates her refusal to receive any type of cardiopulmonary resuscitation, intubation, or maintenance of life support on mechanical ventilation. Her son, who has a durable power-of-attorney for her healthcare decisions, objects to the discontinuation of mechanical ventilation and wishes that his mother be kept alive without suffering in the chance that she might recover. Which of the following is the most appropriate response to her son regarding his wishes for his mother?

“Based on her wishes, mechanical ventilation must be discontinued.”

“We will take every measure necessary to prolong her life.”

“She may be eligible for hospice care.”

“The opinion of her primary care physician must be obtained regarding further steps in management.”

“Further management decisions will be referred to the hospital’s ethics committee.”

A 28-year-old woman is brought to the emergency department after being resuscitated in the field. Her husband is with her and recalls seeing pills beside her when he was in the bathroom. He reveals she has a past medical history of depression and was recently given a prescription for smoking cessation. On physical exam, you notice a right-sided scalp hematoma and a deep laceration to her tongue. She has a poor EEG waveform indicating limited to no cerebral blood flow and failed both her apnea test and reflexes. She is found to be in a persistent vegetative state, and the health care team starts to initiate the end of life discussion. The husband states that the patient had no advance directives other than to have told her husband she did not want to be kept alive with machines. The parents want all heroic measures to be taken. Which of the following is the most accurate statement with regards to this situation?

The patient’s husband may be appointed as her health care surrogate and may make end-of-life decisions on her behalf.

The physician may be appointed as the patient’s health care surrogate and may make end-of-life decisions on her behalf.

The patient’s parents may be appointed as her health care surrogate and may make end-of-life decisions on her behalf.

An ethics committee must be appointed as the patient’s health care surrogate and may make end-of-life decisions on her behalf.

A court-appointed guardian may be appointed as the patient's health care surrogate and may make end-of-life decisions on her behalf.

A 32-year-old woman is brought to the emergency department by her husband because of an episode of hematemesis 2 hours ago. She has had dyspepsia for 2 years. Her medications include occasional ibuprofen for headaches. After initial stabilization, the risks and benefits of upper endoscopy and alternative treatments, including no therapy, are explained thoroughly. She shows a good understanding of her condition and an appreciation of endoscopic treatment and its complications. She decides that she wants to have an endoscopy to find the source of bleeding and appropriately manage the ulcer. Her medical records show advance directives that she signed 3 years ago; her sister, who is a nurse, has a durable power of attorney. Regarding obtaining informed consent, which of the following is the most accurate conclusion for providing endoscopic treatment for this patient?

Documentation of her decision prior to treatment is required

There are reasons to believe that she may not have decision-making capacity

Endoscopic treatment may be performed without further action

Her sister must sign the consent form

Her decision to have an endoscopy is not voluntary

A 68-year-old man comes to the emergency department because of sudden onset abdominal pain for 6 hours. On a 10-point scale, he rates the pain as a 8 to 9. The abdominal pain is worst in the right upper quadrant. He has atrial fibrillation and hyperlipidemia. His temperature is 38.7° C (101.7°F), pulse is 110/min, and blood pressure is 146/86 mm Hg. The patient appears acutely ill. Physical examination shows a distended abdomen and tenderness to palpation in all quadrants with guarding, but no rebound. Murphy's sign is positive. Right upper quadrant ultrasound shows thickening of the gallbladder wall, sludging in the gallbladder, and pericolic fat stranding. He is admitted for acute cholecystitis and grants permission for cholecystectomy. His wife is his healthcare power of attorney (POA), but she is out of town on a business trip. He is accompanied today by his brother. After induction and anesthesia, the surgeon removes the gallbladder but also finds a portion of the small intestine is necrotic due to a large thromboembolism occluding a branch of the superior mesenteric artery. The treatment is additional surgery with small bowel resection and thromboendarterectomy. Which of the following is the most appropriate next step in management?

Proceed with additional surgery without obtaining consent

Decrease the patient's sedation until he is able to give consent

Contact the patient's healthcare POA to consent

Ask the patient's brother in the waiting room to consent

Close the patient and obtain re-consent for a second operation

A 72-year-old man presents to the emergency department with chest pain and shortness of breath. An EKG demonstrates an ST elevation myocardial infarction, and he is managed appropriately. The patient suffers from multiple comorbidities and was recently hospitalized for a myocardial infarction. The patient has a documented living will, which specifies that he does wish to receive resuscitative measures and blood products but refuses intubation in any circumstance. The patient is stabilized and transferred to the medical floor. On day 2, the patient presents with ventricular fibrillation and a resuscitative effort occurs. He is successfully resuscitated, but his pulmonary parameters warrant intervention and are acutely worsening. The patient's wife, son, and daughter are present and state that the patient should be intubated. The patient's prognosis even with intubation is very poor. Which of the following describes the best course of action?

Do not intubate the patient given his living will

Intubate the patient - the family is representing the patient's most recent and accurate wishes

Consult the hospital ethics committee

Intubate the patient - a patient's next of kin take precedence over a living will

Do not intubate the patient as his prognosis is poor even with intubation

POLST paradigm for USMLE Step 1: High-Yield Patient Safety Lessons

POLST Paradigm - What's the Order?

The POLST (Physician Orders for Life-Sustaining Treatment) form translates a patient's wishes into actionable medical orders, crucial for those with serious illness. It follows a standard decision-making sequence.

📌 Allow CPR? → Basic/Full Interventions? → Calories (Tube Feed)? → Document & Sign.

⭐ A POLST is a physician's order, effective immediately and valid across care settings. It complements an advance directive but does not replace the need for one (e.g., appointing a proxy).

Washington POLST Form Example

POLST Form Sections - The Nitty Gritty

Blank POLST Form (Hawaii) with Sections A, B, and C

A POLST form is typically divided into standardized sections, translating patient wishes into actionable medical orders.

Section	Focus & Orders
Section A	Cardiopulmonary Resuscitation (CPR): A definitive choice between "Attempt CPR" or "Do Not Attempt CPR" (DNR) if the patient has no pulse and is not breathing.
Section B	Medical Interventions: Defines the overall goal of care. - Full Treatment: Aims to prolong life by all medically effective means. - Selective Treatment: Goal-oriented care, may include IV antibiotics or fluids but avoids ICU level care. - Comfort-Focused Treatment: Focus is solely on maximizing comfort.
Section C	Artificially Administered Nutrition: Specifies whether to use feeding tubes, often with options for a trial period.

POLST vs. ADs - The Legal Showdown

A POLST translates patient wishes into actionable medical orders, while Advance Directives (ADs) state future care preferences. They are not mutually exclusive and can coexist.

Feature	POLST (Physician Orders for Life-Sustaining Treatment)	Advance Directives (e.g., Living Will)
Population	Patients with serious illness or frailty, near end-of-life.	All competent adults, regardless of health status.
Document Type	Actionable medical order, signed by a healthcare provider.	Legal document expressing future wishes; not a direct order.
Immediacy	Guides immediate treatment decisions during a medical crisis.	Guides future hypothetical situations; requires interpretation.
Portability	Standardized form that travels with the patient across care settings.	May not be easily accessible or transferable between facilities.

Clinical Use Cases - When Seconds Count

For incapacitated patients, the POLST form translates wishes into actionable medical orders. It is a critical tool for EMS and emergency departments, providing immediate, clear directives on life-sustaining treatments. This avoids ambiguity when time is critical, ensuring patient preferences regarding CPR, mechanical ventilation, and other medical interventions are respected without delay.

⭐ POLST forms are legally recognized medical orders, not just advance directives. They must be followed by healthcare providers, including EMS, across different care settings, carrying more immediate authority than a living will.

High‑Yield Points - ⚡ Biggest Takeaways

The POLST is a portable medical order, not just an advance directive, for patients with serious advanced illness.

It translates patient preferences into actionable orders for treatments like CPR, medical interventions, and artificial nutrition.

Signed by the patient (or surrogate) and a physician, it has legal authority across care settings.

It provides specific medical instructions that are effective immediately, unlike a living will.

Complements but does not replace traditional advance directives, providing more specific guidance.

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POLST paradigm