The Physician Orders for Life-Sustaining Treatment (POLST)
Information for Patients and Family Members
(written for residents of Washington State)
Who should have a POLST form?
The POLST (Physician Orders for Life-Sustaining Treatment) form is intended for people with serious health conditions.
Why should I have a POLST form?
If you have a serious health condition, you need to make decisions about life-sustaining treatment. Your physician can use the POLST form to represent your wishes as clear, specifically written medical orders.
What is the POLST form?
The POLST form is a bright lime green, medical order form. Your physician may use the POLST to write orders that indicate what types of life-sustaining treatment you want or do not want, at the end of life. The POLST form asks for information about:
•your preferences for resuscitation
•medical conditions
•the use of antibiotics
•artificially administered fluids and nutrition.
What does the POLST form do?
The POLST form is voluntary and is intended to:
•help you and your physician discuss and develop plans to reflect your wishes;
•assist physicians, nurses, health care facilities and emergency personnel in honoring your wishes for life-sustaining treatment;
•direct appropriate treatment by Emergency Medical Services personnel.
Does the POLST form need to be signed?
Yes. A physician must sign this bright lime green form in order for it to be a physician order that is understood and followed by other health care professionals.
If I have a POLST form, do I need an advance directive, too?
If you have a signed POLST form, it is recommended that you also have an advance directive, though this is not required. You may obtain more information about advance directives from your physician, your health insurance provider, or from the Washington State Medical Association (WSMA): 1-800.552-0612
What if my loved one can no longer communicate her/his wishes for care?
If you are the designated health care representative, you can speak on behalf of your loved one. A physician can complete the POLST form based on your understanding of your loved one’s wishes.
Where is the POLST form used?
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.
Who keeps my POLST form?
If you live at home, you keep the original green POLST form in a prominent location (e.g., on the refrigerator or in your medicine cabinet). If you live at a long-term care facility, your POLST will be kept in your medical chart along with other medical orders.
What are some of the medical terms used when talking about end-of-life care?
•POLST: Physician Orders for Life-Sustaining Treatment. A medical order form that turns your wishes for life-sustaining treatment into action.
•Comfort measures: Medical care undertaken with the primary goal of keeping a person comfortable rather than prolonging life. On the POLST form, a person who requests "comfort measures only" would be transferred to the hospital only if it is needed for his or her comfort.
•Cardiopulmonary resuscitation (CPR): Attempts to restart breathing and the heartbeat of a person who has no heartbeat or has stopped breathing. Typically involves "mouth to mouth" resuscitation and forceful pressure on the chest to restart the heart. May also involve electric shock (defibrillation) or a plastic tube inserted in the throat and into the windpipe to assist breathing (intubation).
•Mechanical ventilation/respiration: A plastic tube is put down the throat to help breathing. A machine pumps air in and out of the lungs through the tube when a person can no longer breathe on their own.
•Antibiotics: Antibiotics fight infections (such as pneumonia) that can develop when a person is seriously ill.
•Artificial Fluids and Nutrition: When a person can no longer eat or drink by mouth, fluids and liquid nutrients can be given to them by IV or tube-feeding.
oIntravenous (IV) fluids: A small plastic tube (catheter) is inserted directly into the vein and fluids are administered through the tube. Typically, IV fluids are given on a short-term basis.
oTube-feeding: On a short-term basis, fluids and liquid nutrients can be given through a tube in the nose that goes into the stomach (nasogastric or "NG" tube). For long-term feeding, a tube can be inserted though a surgical procedure directly into the stomach (gastric or "G" tube) or the intestines (jejunal or "J" tube).
•Dialysis: A mechanical process used to clean the blood to remove waste and excess fluids when the kidneys fail.
•Advance Directives: Advance directives are written instructions stating how you want your future medical decisions made, in the event that you become unable to make or to communicate such decisions for yourself. The two most common advance directives are a living will and a medical power of attorney.
Health Care Representative: If you are unable to make decisions for yourself, state law requires that a family member (for example, a spouse) be asked to serve as your representative and make decisions for you. If you have completed a medical power of attorney, the person designated on that form will be your legal health care representative.