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POLST, or Portable Orders for Life-Sustaining Treatment, helps give seriously ill patients more control over their care.

POLST

If you are seriously ill or in very poor health, your health care provider can use the Portable Orders for Life-Sustaining Treatment (POLST) to represent your wishes for future care as clear and specific medical orders, indicating what types of life-sustaining treatment you want or do not want in the case of a medical emergency.

Is POLST for You?

If you have poor health from one or more chronic or serious medical conditions, it is important to talk to your health care provider about the risks you face if you were to have a medical emergency. You may want to make decisions about whether you would want to have life-sustaining treatments, such as cardiopulmonary resuscitation, started by emergency responders and be taken to a hospital or intensive care unit. Some people with poor health want to have the choice to not pursue some treatments in an emergency.

Your health care provider can use the Portable Orders for Life-Sustaining Treatment (POLST) to represent your wishes as clear and specific medical orders, indicating what types of life-sustaining treatment you want or do not want in these emergencies.

POLST is not for everyone. POLST is designed for seriously ill individuals, or those who are in very poor health*, regardless of their age.

Learn more about POLST in the frequently asked questions sections at bottom.

How to obtain POLST

Patients are encouraged to ask their health care providers for POLST but may also obtain a form by sending a self-addressed, stamped envelope to WSMA, Attn: POLST, 2001 6th Ave., Suite 2700, Seattle, WA 98121.

Health care professionals may order a supply of POLST forms as well as a tri-fold patient information brochure on POLST below. POLST materials are free for WSMA members. Limited quantities are available to clinics and hospitals. A small fee is charged for non-members.

Health care organizations and professionals may choose to print their own copies of POLST. We advise that you print the English version of the form on green card stock (Astrobrights terra green, smooth finish, 65 lbs., #22781, or an equivalent). Please keep in mind that copies, digital images and faxes are valid as is POLST on different paper. Many institutions use a bright lime green printer-weight paper.

English POLST form-for-print

English POLST tri-fold patient brochure

The POLST form and tri-fold patient brochure are translated into the following languages.

Chinese (Simplified) POLST form and brochure

Chinese (Traditional) POLST form and brochure

Korean POLST form and brochure

Russian POLST form and brochure

Spanish POLST form and brochure

Tagalog POLST form and brochure

Vietnamese POLST form and brochure

Additional POLST information, including educational videos, are available in the POLST Information for Health Professionals section below.

POLST Form
POLST Form

The Portable Orders for Life-Sustaining Treatment (POLST) form represents a way of summarizing wishes of an individual regarding life-sustaining treatment. The form is intended for any individual with an advanced life-limiting illness.

Non-member price: 0.75
Member price: 0.00
0.75
POLST Brochure
POLST Brochure

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.

Non-member price: 0.75
Member price: 0.00
0.75

Non-member orders of 50 or more POLST forms or POLST brochures  are $.25 each.

POLST Information for Health Professionals

Who should have POLST?

It is recommended that health care providers (MD, DO, ARNP, PA-C) ask themselves, “Would I be surprised if this patient died in the next 1-2 years?” If you would NOT be surprised, this person probably has a serious or chronic progressive health condition that is either nearing its end stages or is likely to progress to a life-threatening state suddenly. This person would benefit from a conversation with you about the kind of care they would want in an emergency. When POLST is used to document decisions and preferences about emergency measures and other medical care, with proper signatures, it becomes an actionable order that can be honored across settings, from home to long-term care to the hospital is an emergency.

How is POLST used?

POLST is used to tell health care personnel, especially emergency responders and those working in out-of-hospital settings, what level of care the person would want in an emergency. This includes an actionable ‘code status’ order.

In a health care facility, the form should be the first document in the clinical record and should also be posted in an accessible location close to the patient. It should be recognized as a set of medical orders, to be implemented as any other signed health care provider order 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.

The completed POLST is a portable medical order form; it should remain with the individual if they are transported between care settings, regardless of whether they 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.

POLST "dos and don'ts" for clinicians

DO remember to sign and date the form. Signatures of both the signing clinician and the individual (or their legal medical decision maker) are required.

DO be aware that, while POLST can be signed by surrogate decision makers, it is best if the individual signs the POLST indicating that it represents their wishes. When this is not possible, the health care provider and the surrogate decision maker should ensure that the POLST agrees with the individual’s prior directives or their known wishes, or is in their best interest, given what is known about their values and goals.

DO make sure that the patient understands the treatment options at each level of care.

DO discuss the person’s preferences regarding medically assisted nutrition i.e., artificial feeding. Indicate on side 2 of the POLST if the patient has preferences that would inform discussions about medically assisted nutrition.

DO recognize that a patient wishing DNR for cardiopulmonary arrest might still want full treatment. This can be indicated by checking DNAR in Section A and Full Treatment in Section B.

Do ensure that if a person chooses to have CPR (YES in Section A), they should be advised to choose Full Treatment in Section B, since CPR frequently includes intubation and ICU care.

DO consider introducing POLST to Alzheimer’s patients while they can consider and sign the documents themselves. Discuss “down the road” scenarios thoroughly, so that patients can opt to amend prior documents to properly instruct their families about what future choices might be.

DO work with administrators in facilities where you are an attending or serve as medical director to ensure that there is a timely process for discussing and completing POLST and policies that outline how members of their team will honor POLST.

DO be aware that, while Medicare requires health care institutions to ask about advance care planning documents, it prohibits them from compelling or requiring patients have these forms, including POLST.

DON’T pre-sign forms for facility settings.

DON’T send the form home with a patient to fill out on their own. If a patient wants to show the form to their family or surrogate decision-makers, DO set up an appointment to have them review it with you for final decisions and signatures.

Summary of 2021 form revisions

POLST was revised in 2021 (the new version is marked "Revised 4/2021"). Review a summary of those revisions. Previous versions of the form will continue to be honored, but we encourage those filling out new POLST orders to use the most current version.

Spanish-language POLST resources

Download a Spanish-language version of the POLST patient brochure (download only; not available in print).

Also available: An educational DVD, "Honoring the Wishes of the Spanish Speaking Patient & Family." This 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.

POLST, nursing assistants and other caregivers

In 2015, the Department of Health’s Nursing Care Quality Assurance Commission issued an advisory opinion and FAQ document clarifying that nursing assistants and other non-credentialed UAP (unlicensed assistive personnel) may honor a no-CPR order indicated in a patient’s POLST. This change in guidance will hopefully make it possible for more bedside caregivers to honor patient decisions to refuse CPR. The opinion was the result of several years of effort by the WSMA, through its POLST Task Force and End-of-Life Coalition, with the assistance of DSHS and stakeholders within the long-term care industry, and marks an important milestone in the acceptance of the POLST. Find the opinion and FAQ on the DOH Nursing Commission webpage.

With the Nursing Commission’s decision providing clarity on the issue, facilities employing nursing assistants and other caregivers can move forward with providing POLST training. To meet this need, the WSMA now offers a video titled "Honoring POLST in Private Homes and Residential Care Settings," which facilities can use to train caregivers in home-based and residential settings to follow Section A of the POLST form (the section indicating the patient’s wishes for resuscitation).

PLEASE NOTE: A previous version of the Washington POLST was used in making the video. The directions and content of the video and accompanying training are still valid with the newest version of the POLST.

Sample POLST policies for facilities

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

Sample policy on Virtual /Remote signing of POLST can be found here: (add sample policy)

POLST contacts

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

Bruce Smith, MD, (Bruce.Smith2@providence.org), physician perspective, co-chair of Washington POLST Task Force
Sharmon Figenshaw, ARNP, CHPN, (sharmon.f@icloud.com), hospice/palliative care perspective, co-chair of Washington POLST Task Force
Catie Holstein, EMS & Trauma Supervisor, Dept. of Health, EMS Section & Trauma Prevention, (catie.holstein@doh.wa.gov), emergency medical service perspective
Brendan Cox, (brendan@wsma.org), for questions regarding the management of the statewide POLST program

POLST research

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
360.236.2841, 800.458.5281
website

Washington State Hospital Association
206.281.7211
website

National POLST Paradigm
c/o Emmer Consulting, Inc.
208 I Street NE Washington DC 20002
www.polst.org

Organizations that endorse the use of POLST

  • ARNPs United of Washington State
  • Association of Washington Public Hospital Districts
  • National POLST
  • Washington Academy of Physician Assistants
  • Washington Health Care Association
  • Washington Osteopathic Medical Association
  • Washington State Department of Health
  • Washington State Hospice & Palliative Care Organization
  • Washington State Hospital Association
  • Washington State Medical Association
  • Washington State Nurses Association

POLST FAQs for Patients

Review the following frequently asked questions to learn more about POLST. If you still have questions, please speak with your health care provider to learn more and to find out if POLST is right for you.

What is the POLST form?

POLST is a physician order that helps give seriously ill patients more control over their end-of-life care. Produced on distinctive bright green paper and signed by both the clinician and patient, POLST specifies the types of medical treatment that a patient wishes to receive toward the end of life. As a result, POLST can prevent unwanted or medically ineffective treatment, reduce patient and family suffering, and help ensure that patients’ wishes are honored.

How is POLST different from my advance directive? Do I need both?

Every adult can benefit from having conversations with their health care professionals and trusted people in their life about what they might want for medical care if a sudden emergency, accident or illness were to happen. These conversations, and the decisions you make, should lead to having documents called advance directives.

Advance Directives can indicate:

  1. Who you choose to be your legal medical decision maker, also known as medical surrogate, healthcare agent). This is documented in a type of advance directive known as a durable/medical power of attorney for healthcare (DPOA-HC)
  2. Information about what matters to you, what makes your life worth living, and specific decisions you might want to make about:
    -- whether to have life-saving, or life-prolonging treatments such as CPR,
    --what level of care you might want in a hospital, whether to have artificial fluids and feeding, dialysis or care in an intensive care unit (ICU). ICU care usually involves more complicated and invasive kinds of medical care (e.g., machines that support breathing and heartbeat, extreme treatments aimed at keeping you alive).

Some Durable Power of Attorney for Healthcare (DPOA-HC) forms allow you to add this information (link to honoring choices form). Or you may want to complete a type of advance directive known as a health care directive (link to HC HCD) which will also ask about your choices for medical care if you are diagnosed with a terminal illness or a condition known as a permanent vegetative state.

What are my options for life-sustaining treatment?

You have the power to determine the kind of treatments you want to receive and the kind of treatments you want to avoid. To help you understand your options, visit the new Honoring Choices Pacific Northwest website for information that will help you begin these conversations with your family and health care professionals.

What information is included on the POLST form?

The decisions documented on the POLST form include whether to:

  • Attempt cardiopulmonary resuscitation (CPR).
  • Administer antibiotics and IV fluids.
  • Use a ventilator to help with breathing.
  • Provide artificial nutrition by tube.

Does a POLST form limit the type of treatment I can get? What if I get a simple infection?

POLST gives you more control over receiving treatments you want to receive and avoiding treatments you do not want to receive in the event you are unable to speak for yourself during a medical emergency. If you want everything possible done during a medical emergency, then your health care professional would complete the form showing “CPR” and “Full Treatment.” Conversely, if you want other treatment, your health care professional would complete the form showing “Comfort Measures Only” or “Limited Treatment.”

Additionally, POLST states that ordinary measures to improve the patient’s comfort, and food and fluid by mouth as tolerated, are always provided.

Is POLST required by law?

No. Completing a POLST form should always be voluntary.

Who would benefit from having a POLST form?

POLST is not for everyone. POLST is designed for seriously ill individuals, or those who are in very poor health, regardless of their age.

Most people are too healthy to need a POLST. If something suddenly happened, many healthy seniors would want everything done while more was learned about what was wrong and about their chances of recovery. Healthy people should have an advance directive. Later, if the patient became sicker or frailer, they or their surrogate (for example, their power of attorney for health care) can complete a POLST to turn their treatment wishes into medical orders.

Does the POLST form replace traditional advance directives?

POLST complements an advance directive and is not intended to replace that document. An advance directive is still necessary to appoint a legal health care decision maker, and is recommended for all adults, regardless of their health status.

If someone has a POLST form and an advance directive that conflict, which takes precedence? If there is a conflict between the documents, the more recent document generally would be followed.

Who completes the POLST form?

A health care professional, usually a doctor, nurse, physician assistant or social worker, completes the form after having a conversation with the patient to understand his/her wishes and goals of care. Once completed, POLST must be signed by both the patient and either their physician (MD/DO), a nurse practitioner (ARNP) or a physician assistant-certified (PA-C). The physician, nurse or physician assistant that signs the form assumes full responsibility for its accuracy.

Patients should not be provided a POLST form to complete on their own. A POLST form should never be completed without a conversation with the patient, or his/her surrogate, about diagnosis, prognosis, treatment options and goals of care.

Can the physician signing the POLST form be a naturopath or chiropractor?

At this time, a physician signing the POLST should be an MD (Doctor of Medicine) or DO (Doctor of Osteopathic Medicine). An advance registered nurse practitioner (ARNP) or physician assistant certified (PA-C) may also sign the form.

What happens to my POLST form after it is completed and signed?

What if my loved one can no longer communicate her/his wishes for care? A health care professional can complete the POLST form based on family members’ understanding of their loved one’s wishes. The appointed surrogate decision maker can then sign the POLST form on behalf of their loved one.

The original POLST form, on bright green paper, stays with you at all times. In a hospital, nursing home or assisted living facility, the form will be in your medical record or file. If at home, place your form in a visible location so it can be found easily by emergency medical personnel, usually on a table near your bed, or on the refrigerator.

Can I change my POLST form?

Yes, you can change your POLST at any time should your preferences for treatment change. It is a good idea to review the decisions on your POLST form when any of the following occur:

  • You are transferred from one setting to another—for example you go from your home to the hospital, or you are discharged from the hospital to a nursing home.
  • There is a change in your overall health, or you are diagnosed with an illness.
  • Your treatment preferences change for any reason.

What happens if I don’t have a POLST form?

Without a POLST form, emergency medical personnel, nurses and doctors would not know your treatment wishes. You will most likely receive all possible treatments, whether you want them or not. Talking about your treatment choices with your loved ones and doctor before a problem occurs can guide them and help ensure you get the care you want.

Are faxed copies and/or photocopies valid? Must green paper be used?

Faxed copies and photocopies are valid. Bright green paper is used to distinguish the form from other forms in the patient’s record; however, the form will be honored on any color paper.

Is POLST available as a wallet card or bracelet?

At this time, the Washington state POLST is only available in its standard size—some facilities have on occasion created on their own “pocket” versions of POLST, but these variations of the standard size form are not officially sanctioned by the POLST-sponsoring organizations (the WSMA and the Department of Health).

In Washington state, the Department of Health instructs their paramedics to be guided by the POLST form and only the POLST form. While a “pocket” POLST, or bracelets and necklaces could alert a first responder as to a person's wishes and may encourage them to find the POLST form, medics in Washington are not allowed to act on directions found on that pocket card, or bracelets/necklaces alone.

Can I request a DNR (Do Not Resuscitate) bracelet from my provider?

While some states allow bracelets to serve as instructions to be followed by paramedics in the field, in Washington state, the POLST form is the only set of medical orders approved by the Department of Health that paramedics and emergency medical services teams can follow outside of a medical facility. Bracelets and necklaces could alert a first responder as to a person's wishes and could certainly encourage them to find the POLST form, but Washington state medics are not allowed to act directions found on bracelets or necklaces alone.

Where is POLST used now?

POLST was originally developed in Oregon. There are a number of states that currently have POLST programs in place or that are developing POLST programs. For more information on the national POLST effort, visit www.polst.org.

What if I travel to another state—will my POLST be valid?

If you are traveling to another state, it is a good idea to take both your advance directive and your POLST form with you. Both documents, even if not legally binding, will help health care providers know your wishes.

What if I move to another state—will my POLST be valid?

If you are moving, you should bring your POLST with you to your first appointment with your new health care professional to put your wishes on that state’s POLST form (for a list of states with POLST programs, visit the national POLST program website at www.polst.org). You should also talk to your attorney about updating your advance directive, as some states require you use a specific form in order for your advance directive to be valid.

Do emergency responders in Washington honor the Oregon POLST and vice/versa?

EMTs in Washington state will do their best to honor other state POLST forms as long as the other state form has the basic elements of the Washington form. One significant difference between the Oregon and Washington forms is that a patient signature is required on the Washington state form, but not on the Oregon form. Providers and patients/surrogates need to be aware that if they choose not to sign an Oregon POLST, it may be harder for the EMS or physicians in Washington to honor it.

The Washington POLST will be accepted and honored in Oregon by both EMS and the local hospitals.

It’s recommended that a patient fill out a form for the state where they reside.

Is there a state registry for POLST?

There is not a state registry in Washington state at this time.

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