Physician Orders for Life Sustaining Treatment (POLST)

The Physician 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 a serious illness.

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.

About POLST

Frequently asked questions
How to order
Downloadable form (for providers only)
Summary of December 2010 form revisions
Educational resources
Sample POLST policies for facilities
POLST contacts
POLST articles/studies
Other resources
Organizations that endorse the use of the POLST Form

Frequently asked questions regarding the POLST form

What is the POLST form?

The Physician 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.

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.

The attending physician, nurse practitioner or PA-C should complete the document with the patient. The attending physician, ARNP or PA-C must sign the form and assume full responsibility for its accuracy.

The POLST form facilitates the process of translating end-of-life discussions with patients into actual treatment decisions, and provides security for the individual and physician that the expressed wishes will be carried out. There is no other form that streamlines the process in this way.

How is the 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

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, 2033 Sixth Avenue, Suite 1100, Seattle, WA 98121.

Providers can order bulk supplies of POLST forms and patient brochures at the WSMA online store.

We'd like to encourage any and all institutions to consider printing their own copies of the POLST form. To help you do this, we provide a master copy of the form for you to print and use to make copies, as well as instructions as to the type of paper you need.


Downloadable POLST form (for providers only)

This downloadable POLST form is meant to serve as a master copy to be used to print bulk quantities (or single copies) of the form. It should be printed 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 2011 (the new version is marked "Revised 2/2011"). Previous versions of the form will continue to be honored.

Download the master copy POLST form for print. [PDF]

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


Summary of December 2010 form revisions

A summary of revisions [PDF] made to the POLST form in December of 2010.


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 a PDF of the English patient brochure.

Click here to download a PDF of the Spanish patient brochure.

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

This educational film (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. This DVD 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 Justin Dale, jod@wsma.org or (206) 956-3633.

"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. [PPT]

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. These volunteers come from a variety of health professions; choose the one most closely related to the subject of your query. 

Bruce Smith, MD, (smith.bc@ghc.org), physician perspective
Sharmon Figenshaw, ARNP, CHPN, (sharmon.figenshaw@providence.org), hospice/palliative care perspective
Michael Lopez, Dept. of Health, (Michael.lopez@doh.wa.gov), Emergency Medical Services (EMS) provider perspective
Graham Short (WSMA staff), (gfs@wsma.org), for questions regarding the management of the statewide POLST program


POLST articles/studies

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

Improving Advanced Illness Care: The Evolution of State POLST Programs – AARP Public Policy Report, by Naomi Karp by AARP Public Policy Institute and Charles Sabatino, the American Bar Association, April 2011. Download a two-page study synopsis. [PDF]

New Efforts to Simplify End-of-Life Care Wishes – The Wall Street Journal, published March 15, 2011

Doctors’ orders help patients get the end-of-life care they want – Seattle/LocalHealth Guide, published July 2, 2010

Oregon's POLST form helps clarify end-of-life decisions – OregonLive.com, published July 01, 2010


Other POLST resources

Washington State Department of Health

Office of Emergency Medical Services and Trauma System
P.O. Box 47853
Olympia, WA 98504-7853
(360) 236-2828
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

POLST form

 

 

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