The Physician Orders for Life Sustaining Treatment (POLST) form is a written medical order from a physician, nurse practitioner or physician assistant that helps give people with serious illnesses more control over their own care by specifying the types of medical treatment they want to receive during serious illness.

Key Facts About a POLST:

A POLST is not for everyone. The POLST form is designed for people who have chronic health conditions and/or those who are seriously ill or medically frail. A POLST is most useful for people who want less than fully aggressive medical treatment in their current health state. 

Filling out a POLST is voluntary. Nursing homes and assisted living facilities may include the POLST in their admission papers, but you are not required to complete a POLST if you do not wish to.

Don’t complete the form until you’ve had an in-depth discussion. You should not fill it out a POLST form until you’ve had a good talk with your doctor or another trained medical professional who can explain the form’s medical terms and options and how they relate to your current medical condition. It can be very helpful to include your family members in the conversation so they understand your health condition and are aware of your treatment wishes.

The POLST form is not valid until it is signed by you (or if you are not able, your appropriate decisionmaker) AND your physician/nurse practitioner/physician assistant.

A POLST form does NOT replace an advance directive. An advance directive is the way to appoint a legal Health Care Agent, and is recommended for all adults. A POLST can work together with your advance directive, providing specific detail regarding treatment wishes. 

The original bright pink copy of the POLST travels with you to different health care settings – home, assisted living, nursing home or hospital. Wherever you go for care, the original pink form should go with you, and be kept in an easy to find place. To make sure it is found if needed, some people put it on their refrigerator.

You only have to complete a new POLST if your treatment wishes change. You do not need to fill out a new POLST if you move from one facility to another, or change doctors.

Because the POLST form is a medical order, emergency medical personnel are required to follow its instructions regarding CPR and other emergency medical care. The POLST form is printed on bright pink paper so it will be easily recognizable by all health care personnel.

You can change or void your POLST form, at any time.  To change your POLST instructions, complete a new POLST form, sign and date it, and have your doctor sign it. To void the old form, draw a line through sections A through D, write “VOID” in large letters, then sign and date the line. 

View/Download the POLST Form & Instructions – The POLST form, instructions, and translations into multiple languages, can be downloaded and printed from