Background In the US, physician orders for life-sustaining treatment (POLSTs) are widely distributed. In Europe, on the other hand, emergency orders are still rarely reported from the ambulatory setting short of palliative care. There is a number of challenging conceptual and ethical questions involved in the POLST issue that have received little attention yet.

Methods This analysis is based on a systematic literature search, and further draws on our experience with introducing a variant of the POLST, the POLST-in-case-of-emergency (POLST-E), into our German regional ACP program beizeiten begleiten® (‘be caring betimes’) that is based on Respecting Choices®.

Results POLSTs feature an implicit dual nature: On the one hand, they are a physician's order – on the other, (part of) an advance directive (by proxy). However, the conceptual relation between advance directives (ADs) and POLSTs seems not clear, and neither do the requirements for a skilled facilitation process before a POLST should be signed by all participating parties. A number of other questions deserve consideration, i.e. whether POLSTs are reserved for the terminally ill, or also eligible for the healthy; whether they relate only to the setting where they were originally discussed; and which treatment issues they should (not) cover, with particular consideration of the availability of prognostic information.

Discussion In summary, the POLST instrument bridges a year-long gap between ADs and emergency requirements. However, unreflected use of the POLST may come along with significant risks and potential side effects, therefore open conceptual and ethical questions deserve debate.