POLST forms are different in each state- the order of the sections or the options within a section may be different- but they cover the same information. Below provides information about the forms. If you have any questions, talk to your health care professional.
Section A: Cardiopulmonary Resuscitation (CPR)
This section only applies when the patient is unresponsive, has no pulse and is not breathing.
This is similar to a Do-No-Resuscitate Order (DNR Order), but a patient only has a DNR Order when they do not want CPR. The POLST form allows patients to clearly show they do want CPR.
If this is left blank, emergency personnel will provide CPR if medically indicated.
Section B: Medical Interventions
This section gives medical orders when CPR is not required but the patient still has a medical emergency and cannot communicate. There are three options and a space for a health care professional to write in orders specific for the patient. Care is always provided to patients. This section is just for letting emergency personnel know what treatments the patient wants to have.
- Full Treatment. The goal of this option is to provide all treatments necessary (and medically appropriate) to keep the patient alive. In a medical emergency patients want to go to the hospital and, if necessary, be put in the intensive care unit (ICU) and on a breathing machine.
- Limited Treatment / Select Treatment. The goal of this option is to provide basic medical treatments. Patients want to go to the hospital but do not want to be put in the intensive care unit (ICU) or on a breathing machine. They are okay with antibiotics and IV fluids.
- Comfort Measures Only. The goal of this option is to focus on making the patient as comfortable as possible where they are. Patients do not want to go to the hospital. If the patient’s comfort cannot be taken care of where they are, transfer to the hospital may be necessary.
In many states, if a patient chooses CPR or leaves Section A blank, he/she is required to choose “Full Treatment” in Section B. This is because CPR usually requires intubation and a breathing machine, which are only options under “Full Treatment”.
This section is the heart of the POLST form. If a patient has a medical emergency but does not want CPR this is the section emergency personnel will look at to see whether the patient wants to go to the hospital or not (for Full Treatment and Limited Interventions- yes; for Comfort Measures Only- no). If the patient only has a DNR order, emergency personnel would take them to the hospital.
Section C: Artificially Administered Nutrition
This section is where orders are given about artificial nutrition (and in some states artificial hydration) for when the patient cannot eat. All POLST forms state that patients should always be offered food by mouth if possible.
Other Section: Signatures
Healthcare professional: Since this form is a medical order a health care professional is required to sign it in order for it to be valid. Which health care professionals can sign (nurse, doctor) varies by state. The form has a statement saying that, by signing the form, the healthcare professional agrees that the orders on the form match what treatments the patient said he/she wanted during a medical emergency based on his/her medical condition today.
Patient or Surrogate: Most states require the patient or his/her surrogate to sign this form. This helps to show the patient or surrogate was part of the conversation and agrees with the orders listed on the form.
Back Side of a POLST Form
The backside of the POLST form has directions and information, usually for healthcare professionals. Other information it may have includes:
- Information on how to void a POLST form;
- Contact information for your surrogate; and
- Information about who completed the POLST form.