POLST — Physician Orders for Life-Sustaining Treatment

POLST/MOLST/POST form — actionable medical orders signed by a physician, PA, or NP for patients with serious illness, complementing (not replacing) an advance directive.

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PHYSICIAN ORDERS FOR LIFE-SUSTAINING TREATMENT
(POLST / MOLST / POST — form name varies by state)

State:              Oregon (POLST)

╔═══════════════════════════════════════════════════════════════════════╗
║  THIS IS A MEDICAL ORDER. Follow these orders unless they conflict   ║
║  with the patient's expressed wishes or condition. This form follows ║
║  the patient across care settings (home, hospital, nursing facility, ║
║  hospice, EMS).                                                      ║
╚═══════════════════════════════════════════════════════════════════════╝

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PATIENT
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Name:               Eleanor Margaret Hayes
DOB:                March 18, 1942
Address:            4112 SE Hawthorne Blvd, Portland, OR 97214

UNDERLYING CONDITION (clinical context)
Stage IV non-small cell lung cancer with brain metastases. Karnofsky performance status 50%. Treating oncologist estimates life expectancy less than 12 months. Patient retains decision-making capacity at time of completion.

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SECTION A — CARDIOPULMONARY RESUSCITATION
(when patient has NO PULSE and is NOT BREATHING)
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Order:   Attempt CPR / full resuscitation

Note: If "Attempt CPR" is selected, also select "Full treatment" in
Section B unless explicitly indicated otherwise. Do Not Attempt
Resuscitation orders apply only when there is no pulse and no
respiration; they do NOT mean "do nothing" in other circumstances —
see Section B for medical interventions when patient has a pulse and
is breathing.

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SECTION B — MEDICAL INTERVENTIONS
(when patient has a pulse and/or is breathing)
═══════════════════════════════════════════════════════════════════════

Order:   Selective treatment — IV fluids, antibiotics, no intubation/ICU

Full treatment: All medically indicated interventions including
intubation, mechanical ventilation, ICU admission, and advanced
cardiac life support. Transfer to higher level of care if needed.

Selective treatment: Treat reversible conditions with IV fluids,
antibiotics, and standard medical care. Do not intubate; do not use
mechanical ventilation; do not transfer to ICU. Transfer to acute
care only if comfort cannot be maintained at current location.

Comfort-focused treatment only: Use medications by any route,
positioning, wound care, and other measures to relieve pain and
suffering. Use oxygen, suction, and manual airway management as
needed for comfort. Do not transfer to acute care unless comfort
needs cannot be met in current location.

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SECTION C — ANTIBIOTICS
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Order:   Use antibiotics if life can be prolonged

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SECTION D — MEDICALLY ADMINISTERED NUTRITION (TUBE FEEDING)
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Order:   Trial period of artificial nutrition

Note: Oral feeding for comfort and pleasure is always offered when
medically possible regardless of selection above.

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SECTION E — BASIS FOR THESE ORDERS
═══════════════════════════════════════════════════════════════════════

Discussed with:     Patient with capacity
If not patient:     Not applicable — discussed with patient.

The orders above were discussed with the person identified above and
reflect the patient's known wishes (or, if patient lacks capacity,
the surrogate's substituted-judgment determination of the patient's
wishes per state law).

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SECTION F — CLINICIAN SIGNATURE (REQUIRED — MAKES ORDERS ACTIONABLE)
═══════════════════════════════════════════════════════════════════════

Clinician:          Dr. Marcus Chen, MD (Physician (MD/DO))
License number:     OR-MD-43219
24/7 contact:       +1 503 494 8311


_____________________________________     May 11, 2026
Clinician signature                        Date

(In states that permit only physician signature, signature must be
MD or DO. In states that permit NP or PA signature, scope-of-practice
rules apply.)

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SECTION G — PATIENT OR SURROGATE SIGNATURE
═══════════════════════════════════════════════════════════════════════


_____________________________________     May 11, 2026
Patient or surrogate signature             Date

Printed name:       Eleanor Margaret Hayes
Relationship to patient (if surrogate):    _____________________________

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INSTRUCTIONS FOR USE
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• Keep ORIGINAL with patient. POLST is portable across settings.
• Display in a visible location at home (refrigerator, bedside).
• Provide copies to: primary care clinician, hospice, home health,
  long-term care facility, all healthcare agents and surrogates.
• EMS will follow POLST orders if available at the scene.
• REVIEW POLST when: patient is transferred between care settings,
  treatment preferences change, or condition changes substantially.
  No mandatory expiration; recommend review at least annually.
• To revoke: draw a line through entire form, write VOID and sign
  with date. Or replace with new POLST. Verbal revocation by patient
  with capacity is also effective; document in medical record and
  void written form.
• POLST does NOT replace an advance directive. POLST translates an
  advance directive into actionable medical orders for current
  serious illness; an advance directive states broader values and
  appoints a healthcare agent for future incapacity.

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COPY TO PATIENT, PROVIDER, REGISTRY (where state has one)
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About this template

POLST (Physician Orders for Life-Sustaining Treatment) — known by various names depending on state, including MOLST (Medical Orders for Life-Sustaining Treatment), POST (Physician Orders for Scope of Treatment), MOST (Medical Orders for Scope of Treatment), TPOPP (Transportable Physician Orders for Patient Preferences), and several others — is a clinical document fundamentally different from an advance directive. An advance directive (living will or healthcare power of attorney) is a legal document executed by a competent adult that expresses general preferences for future incapacity and appoints a healthcare agent. A POLST is a medical order signed by a physician, PA, or NP that translates those preferences into actionable orders for a patient who is currently seriously ill. Two key features make POLST distinct: (1) it is a medical order — once signed by a clinician, it is enforceable across care settings without re-evaluation by each new provider; (2) it follows the patient — paramedics, emergency department physicians, hospice, nursing home staff, and home-care nurses all follow the orders on the POLST. Created in Oregon in 1991 by a multidisciplinary task force led by ethicist Susan Tolle and physician Patrick Dunn, POLST has been adopted in some form by all 50 states (some states use a "POLST-like" form rather than calling it POLST). The National POLST Paradigm (polst.org) maintains state-by-state status and form variations. The intended population is patients with serious illness who would not be surprising to die within the next year — a population for whom CPR or intensive care may not match their goals. POLST is NOT for healthy patients, who should use an advance directive only. POLST sections typically include: (A) CPR — DNR or attempt CPR; (B) Medical interventions — full treatment, selective treatment, or comfort-focused only; (C) Antibiotics; (D) Medically administered nutrition; (E) Basis for orders (patient with capacity, surrogate, etc.); (F) Clinician signature; (G) Patient or surrogate signature. Some state forms include additional sections (mechanical ventilation, dialysis, blood products) or merge sections. State variations matter: (1) Some states require physician signature only (MD/DO); others permit NP or PA. (2) Some states maintain a registry (Oregon, California, New York, others) so EMS can access POLST without the paper form. (3) Some states use bright-color paper (Oregon: pink; New York: bright pink; California: pink) to make EMS recognition easy. (4) Some states require witness or notarization for some sections. (5) Some states permit oral revocation; others require written revocation. (6) Required review intervals vary; most states recommend but do not require periodic review. Common errors: (1) Treating POLST as a substitute for advance directive — it is a complement, not a replacement. (2) Completing POLST for healthy patients without serious illness. (3) Failing to discuss in detail with the patient — POLST should reflect a thoughtful goals-of-care conversation, not a checklist. (4) Inconsistency between sections — e.g., DNR with full treatment is rare and should prompt clarification. (5) Failing to follow POLST after admission to hospital because hospital staff do not know it exists. (6) Failing to update POLST when condition or preferences change. The Centers for Medicare and Medicaid Services in 2016 finalized payment for advance care planning conversations under CPT 99497 and 99498; POLST conversations qualify and should be billed. The Patient Self-Determination Act of 1990 (42 USC § 1395cc(a)(1)(Q)) requires Medicare/Medicaid hospitals, nursing homes, hospices, home-health agencies, and HMOs to ask patients on admission about advance directives — POLST documentation should be reviewed at every transition.

When to use it

  • Patient has a serious illness for whom death within the next year would not be surprising.
  • Patient is in long-term care, assisted living, or hospice.
  • Patient has decided to limit some or all life-sustaining treatments.
  • Translating an advance directive into actionable orders for current illness.
  • When EMS/paramedics need clear orders on whether to attempt resuscitation in a home or facility setting.

What to include

  • Patient identification and underlying condition (clinical context for the orders).
  • CPR order (Attempt or DNR/AND).
  • Medical interventions level (Full / Selective / Comfort-focused).
  • Antibiotics order.
  • Artificial nutrition order.
  • Documentation of who the orders were discussed with (patient, surrogate, agent, parent).
  • Clinician signature with credentials and license — REQUIRED to make orders actionable.
  • Patient or surrogate signature.
  • Date of signature.
  • Clinician 24/7 contact for clarification.
  • Instructions for portability (keep with patient, share with all care settings).

Frequently asked

An advance directive is a LEGAL document executed by a competent adult that expresses preferences for future incapacity and appoints a healthcare agent. It applies to potential future scenarios. A POLST is a MEDICAL ORDER signed by a clinician for a patient who is CURRENTLY seriously ill, translating preferences into actionable orders for current treatment. Advance directive: legal, future-oriented, executed by patient. POLST: medical, current-focused, signed by clinician (with patient or surrogate input). Most patients with serious illness should have BOTH — the advance directive for general values and agent appointment, and the POLST for current actionable orders.
⚠ Legal disclaimer. POLST forms are governed by state law and vary significantly by state. The National POLST Paradigm (polst.org) maintains the standard framework but each state has adopted its own form, sometimes with different name (POLST, MOLST, POST, MOST, TPOPP, others). Some states require physician signature only; others permit NP or PA. Some states maintain electronic registries; others rely on paper forms. The federal Patient Self-Determination Act (42 USC § 1395cc(a)(1)(Q)) requires Medicare/Medicaid providers to ask about advance directives. CMS pays for advance care planning conversations under CPT 99497 and 99498. POLST is a clinical tool that requires a goals-of-care conversation between clinician and patient or surrogate; this template is a generic form — use the specific form authorized in your state. Source references: polst.org (National POLST), state Department of Health POLST programs, CMS Conditions of Participation. Not legal or medical advice — POLST should be completed only after a goals-of-care conversation with a qualified clinician.
Jurisdiction: United States — state POLST / MOLST / POST / MOST statutes (CA Prob. Code §4780+ Physician Orders for Life-Sustaining Treatment Form Act; OR ORS 127.663+; NY Pub. Health Law §2997-c MOLST; 20 Pa.C.S. §54B+; W.Va. Code §16-30C+ POST); polst.org National POLST Paradigm coordination; underlying state advance-directive law.
Last reviewed: 2026-05
Reviewed by ScoutMyTool — consult a licensed attorney for binding use.

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