POLST Forms & Instructions

The Physician Orders for Life-Sustaining Treatment, (POLST) is a physician’s order that outlines a plan of end of life care reflecting both a patient’s preferences concerning care at life’s end and a physician’s judgment based on a medical evaluation.   It’s central aim is to allows a physician and patient to establish default orders concerning end of life care that can then be succinctly and clearly conveyed to other healthcare professionals, facilities, and emergency personnel when a patient is at home, in a long-term care facility, in transit between locations, entering an Emergency Department or being admitted into/discharged from an acute care facility.

The POLST form is completed by a patient’s physician (or by someone who has undergone special training about POLST and who works with the patient’s physician) in conjunction with thorough conversation with the patient regarding the patient’s current and future health conditions and treatment preferences.   Both the physician and patient must sign the POLST.   If the patient lacks capacity to make medical decisions, the patient’s legally recognized decision-maker can participate in both completing and signing the POLST form.

A POLST should be strongly considered for any patient for whom death in the next 12 months would not be surprising.  This includes patients with metastatic or end-stage organ disease, those having a terminal diagnosis, those receiving hospice or palliative care, and those who currently have or have had in the past DNAR status. A POLST may also be appropriate for patients permanently residing in long-term care facilities.
 


A valid POLST form must be completed in ENGLISH.
POLST - English  

All other languages are for EDUCATIONAL Purposes ONLY and will NOT be considered as a valid form if completed. To view a PDF, please click on the links below. 

POLST-Chinese
POLST - Farsi
POLST-Hmong
POLST - Korean
POLST - Russian
POLST - Spanish
POLST-Tagalog
POLST-Vietnamese
 
POLST - Frequently Asked Questions:

POLST - FAQ - English
POLST - FAQ - Spanish
POLST - FAQ - Farsi
POLST - FAQ - Korean
POLST - FAQ - Russian