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POLST Form

Looking for a POLST Form?

POLST forms are medical order forms. They are not available on this website; please contact your state leader if you need a POLST form to bring to your provider.

There is a National POLST Form but most states still use their own state version of POLST. Check this map (PDF) to see what your states does. Your state form is likely very similar to the National POLST Form. (Health care professionals, please visit our information for health care professionals.)

National POLST Form Guide for Patients

Patient Guide to the POLST Form

Download

Making POLST Truly Portable

Article explaining the need for a National POLST Form

Download

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.

Understanding CPR

Watch video from Naveon

What is a DNR Order?

Watch video from Naveon

Copyright ©2020 Care+ Ventures LLC. Videos may not be duplicated or used in any format without the expressed written consent of Care+ Ventures, LLC.

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.

Chart: Options for Initial Treatment Orders

Table showing options for POLST Form Section B, Initial Treatment Orders, and what they mean
View full size chart or Download PDF

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. This chart shows how the three different treatment options answer those questions.

Section B Order Full Treatments Selective Treatments Comfort-Focused Treatments
Will I be transferred to the hospital? Yes Yes You will only be transferred if you can’t be made comfortable where you are.
Will I go to the Intensive Care Unit (ICU)? Yes, if appropriate No No
Will I be put on a breathing machine? Yes, if appropriate No No

Devices Found
in the ICU

Watch video from Naveon

Copyright ©2020 Care+ Ventures LLC. Video may not be duplicated or used in any format without the expressed written consent of Care+ Ventures, LLC.

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.

Feeding Tubes

Watch video from Naveon

Copyright ©2020 Care+ Ventures LLC. Video may not be duplicated or used in any format without the expressed written consent of Care+ Ventures, LLC.

Next Steps

Review What to Know Before Talking About POLST (PDF) and talk to your health care provider if you think you want a POLST form. If you already have a POLST form, see Your POLST to learn how to interpret what it means. Finally, you may want to look at additional patient resources.

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