Physician Orders for Life-Sustaining Treatment (POLST)

The Physician Orders for Life-Sustaining Treatment (POLST) form is a medical order form that allows any individual with a serious illness to summarize their wishes regarding life-sustaining treatment.

This page is intended for health care professionals. If you are a patient, please visit our POLST for patients page.

The form accomplishes two major purposes: It is portable from one care setting to another. It translates wishes of an individual into actual physician orders.

An attending physician, ARNP or PA-C must sign the form and assume full responsibility for its accuracy.

How to order POLST forms and patient brochures

POLST formOrder bulk supplies of POLST forms and patient brochures from the WSMA online store.

Institutions can print their own copies of the POLST form for distribution by using the downloadable form directly below.

Patients are encouraged to ask their physicians for the form, but may also obtain a form (and/or the patient brochure) by sending a self-addressed, stamped envelope to WSMA, Attn: POLST, 2001 Sixth Avenue, Suite 2700, Seattle, WA 98121.

Downloadable POLST (providers only)

This downloadable POLST form may serve as a master copy to be used to print bulk quantities (or single copies) of the form. It is strongly advised to print on 8-1/2" x 11" green card stock, front and back. For the card stock, you can use Astrobrights terra green (smooth finish), 65 lbs. (#22781), or an equivalent.

The POLST form was revised in 2014 (the new version is marked "Revised 4/2014"). Previous versions of the form will continue to be honored.

Download the master copy POLST form for print.

If you have problems with the download, or have questions regarding the printing/distribution of the form, please contact Graham Short toll-free at at 1 (800) 552-0612, or email gfs@wsma.org.

Summary of April 2014 form revisions

A summary of revisions made to the POLST form in April 2014.

Educational resources

POLST information brochure for patients in English and Spanish

This tri-fold brochure is designed for your waiting room and/or to be distributed directly to patients, and contain an overview of and frequently asked questions about the POLST form.

Ordering instructions for the patient brochure. At this time the Spanish language brochure is only available as a download for printing.

Click here to download the English patient brochure.

Click here to download the Spanish patient brochure.

"Honoring the Wishes of the Spanish Speaking Patient & Family."

This on DVD illustrates how POLST can be effective in honoring a person's wishes, while remaining sensitive to the role that family and culture often play in end-of-life decisions. It pays particular attention to those whose first language is Spanish, yet we also believe that it is a wonderful resource for all who are interested in learning more about POLST.

The film is available on a single DVD in both Spanish and English.  The DVD is currently available for free.  To order a copy, contact Abby Vincent, abby@wsma.org or (206) 441-9762.

"Advance Care Planning for Very Ill Clients"

This Power Point presentation, authored by former POLST Task Force co-chair Jim Shaw, MD, and Dick Sayre, Attorney at Law, and current member of the POLST Task Force, is a teaching tool aimed at professionals: medical personnel, attorneys, social workers, and related. It contains information on the most recently updated form (as of 2/2011) and updated supporting data.

Click here to download the presentation.

Sample POLST policies for facilities

The Washington State Hospital Association has a webpage with materials intended to assist facilities in implementing the POLST program. Click here to visit the WSHA POLST page

POLST contacts

The volunteer health professionals below are willing to help answer any questions you might have regarding POLST. 

Bruce Smith, MD, (bruce.smith@regence.com), physician perspective
Sharmon Figenshaw, ARNP, CHPN, (shar@dslnorthwest.net), hospice/palliative care perspective
Dept. of Health, EMS Section & Trauma Prevention, (360) 236-2841, (800) 458-5281, Emergency Medical Services (EMS) perspective
Graham Short, (gfs@wsma.org), for questions regarding the management of the statewide POLST program

POLST articles/studies

For a comprehensive and up-to-date list of POLST research, please visit the national POLST website, www.polst.org.

Other POLST resources

Washington State Department of Health

Office of Community Health Systems
EMS & Trauma Section 
P.O. Box 47853
Olympia, WA 98504-7853
(360) 236-2841, (800) 458-5281
website

Washington State Hospital Association

300 Elliott Avenue West, Suite 300
Seattle, WA 98119-4118
(206) 281-7211
website

POLST.org

Center for Ethics in Health Care
Oregon Health & Science University
3181 S.W. Sam Jackson Park Rd.
Mailcode: UHN-86
Portland, OR 97239-3098
(503) 494-3965
www.polst.org

Organizations that endorse the use of the POLST form

  • Association of Washington Public Hospital Districts
  • Washington State Department of Health
  • Washington State Hospice & Palliative Care Organization
  • Washington State Hospital Association
  • Washington State Medical Association
  • Regional Ethics Network of Eastern Washington and Northern Idaho