Physician Orders for Life-Sustaining Treatment (POLST)
This page is intended for health care professionals. If you are a patient, please visit our POLST for patients page.
The Physician Orders for Life-Sustaining Treatment (POLST) form is a medical order form that allows any individual with a serious illness or frailty to summarize their wishes regarding life-sustaining treatment. The POLST form can provide security for the patient and physician that the patient's wishes will be carried out.
The POLST 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.
Having the conversation
Physicians and other health care providers play a vital role in helping patients understand what treatment options are available, including risks and benefits, so they can make decisions about the care they want should they face a serious illness or injury.
Starting a conversation about end-of-life planning with your patients can be tough, but taking that step can give them hope and put them at ease for whatever may lie ahead. To assist you in encouraging your patients to plan for the future, WSMA's new Honoring Choices Pacific Northwest website has assembled a multitude of resources for physicians, nurses, social workers, chaplains and other health care professionals in Washington state.
How is the POLST form used?
In a health care facility, the form should be the first document in the clinical record. It should be recognized as a set of physician orders, to be implemented as any physicians orders would. In a non-institutionalized setting (such as a home), the bright green form should be located in a prominent location. It will be recognized by emergency personnel as orders to be followed.
How is the form transferred from one setting to another?
The completed POLST form is a physician order form that will remain with you if you are transported between care settings, regardless of whether you are in the hospital, at home or in a long-term care facility. The institution may wish to keep a duplicated copy in the permanent medical record upon discharge.
If I have a POLST form, do I need an advance directive too?
We encourage everyone to have an advance directive, like a durable power of attorney for health care and/or health care directive (also known as a living will). While advance directives are often very helpful in determining end-of-life decisions, they are not required or necessary for having a POLST form.
You may obtain more information about advance directives from your physician, your health insurance provider, or here.
How to order POLST forms and patient brochures
Providers may order 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 firstname.lastname@example.org.
Summary of April 2014 form revisions
A summary of revisions made to the POLST form in April 2014.
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, email@example.com 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.
POLST for Caregivers: Honoring POLST in Private Homes and Residential Care Settings
If you are a part of a care team working in residential care settings, or care for clients in private homes, you may care for people who have POLST forms. This video provides caregivers with the what, when, where and how the POLST form is applied.
This video was created by at team of experts convened by the WSMA, the Washington State POLST Task Force and the Washington State Department of Social and Health Services, and was made possible by a grant from The Retirement Research Foundation through the National POLST Paradigm Task Force.
Sample POLST policies for facilities
The Washington State Hospital Association has a webpage with materials intended to assist facilities in implementing the POLST program.
The volunteer health professionals below are willing to help answer any questions you might have regarding POLST.
Bruce Smith, MD, (firstname.lastname@example.org), physician perspective
Sharmon Figenshaw, ARNP, CHPN, (email@example.com), hospice/palliative care perspective
Catie Holstein, EMS & Trauma Supervisor, Dept. of Health, EMS Section & Trauma Prevention, (firstname.lastname@example.org), emergency medical service perspective
Graham Short, (email@example.com), for questions regarding the management of the statewide POLST program
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
Washington State Hospital Association
EMS & Trauma Section
(360) 236-2841, (800) 458-5281
Center for Ethics in Health Care
Oregon Health & Science University
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