POLST for Providers

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) is a portable medical order form that allows any individual with a serious illness or frailty to summarize their wishes regarding life-sustaining treatment. POLST can provide security for the patient and physician that the patient's wishes will be carried out.

POLST 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.

For additional resources to help physicians and other health care providers assist patients in understanding what treatment options are available at the end of life, including risks and benefits, so they can make decisions about their health care, visit the Honoring Choices Pacific Northwest website.

Learn more about POLST:

Who should have POLST?
How is POLST used?
How to order POLST and patient brochures
Downloadable POLST
Summary of 2017 form revisions
Educational resources
POLST "dos and don'ts" for clinicians
POLST, nursing assistants and other caregivers
Sample POLST policies for facilities
POLST research
Other POLST resources

Who should have POLST?

POLST form It is recommended that physicians and other clinicians ask themselves, “Would I be surprised if this patient died in the next 1-2 years?” Answering no to this question usually indicates that the patient has a serious chronic or acute illness nearing its end stages or likely to progress to a life-threatening state suddenly, and is an appropriate candidate for POLST.

How is POLST 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 physician 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 physician order form that should remain with the patient 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.

How to order POLST and patient brochures

Providers may order POLST forms and patient brochures from the WSMA online store.

Institutions can print their own copies of POLST 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 (for providers only)

This downloadable POLST 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.

POLST was revised in 2017 (the new version is marked "Revised 8/2017"). Previous versions of the form will continue to be honored.

Download POLST for print.

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

Summary of 2017 form revisions

A summary of revisions made to POLST in 2017.

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.

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. This video provides caregivers with the what, when, where and how POLST 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.

POLST "dos and don'ts"" for clinicians

DO remember to sign and date the form. Signatures of both clinician and patient (or surrogate) are required.

DON’T pre-sign forms for facility settings.

DO be aware that, while POLST can be signed by surrogates, it is best if the POLST agrees with the patient’s prior directives or if the patient signs the document themselves.

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.

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

DO discuss the non-emergency medical treatment preferences (Section D) and indicate if the patient has preferences that would limit either use of antibiotics or artificial 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. In general, CPR in Section A should always link with 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.

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.

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).

Sample POLST policies for facilities

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

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, (sharmon.f@icloud.com), hospice/palliative care perspective
Catie Holstein, EMS & Trauma Supervisor, Dept. of Health, EMS Section & Trauma Prevention, (catie.holstein@doh.wa.gov), emergency medical service perspective
Graham Short, (gfs@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

Washington State Hospital Association

(206) 281-7211

National POLST Paradigm

c/o Emmer Consulting, Inc.
208 I Street NE Washington DC 20002

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
  • National POLST Paradigm