National POLST Form Guide for Patients
Patient Guide to the POLST Form
Making POLST Truly Portable
Article explaining the need for a National POLST Form
You may view the guide (above) or videos (below) to learn more about the decisions in each of the sections of the POLST form. Hopefully this information will help you understand some of the important concepts. Your health care provider should have a talk with you about what treatments may be appropriate for you before completing your POLST form (see Advance Care Planning).
Section A: Yes CPR or No CPR
In an emergency, the provider will first check to see if you have a pulse or are breathing. If you aren’t, the most critical question is whether you want cardiopulmonary resuscitation (CPR).
Having a POLST Form that says No CPR in Section A means it is a do not resuscitate, or DNR, order.
These videos explain what CPR involves and why someone might not want CPR, and what a DNR order means, and why someone might consider having one.
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Section B: Initial Treatment Orders
If you have a pulse or are breathing, the next most important question is Do you want to go to the hospital? and, if yes, What treatments do you want there? Section B on most POLST forms provides this information.
The chart below details what the different Section B options mean. This video explains more about what happens in the ICU.
in the ICU
Section D: Medically Assisted Nutrition
Although it isn’t critical for emergency care, it is very helpful for health care providers to know your wishes about feeding tubes, called medically assisted nutrition. Some feeding tubes require a surgery to place them, usually if you are going to be on a feeding tube for longer than two weeks.
This video explains why someone might or might not want to have a feeding tube.