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). ║ ╚═══════════════════════════════════════════════════════════════════════╝ ═══════════════════════════════════════════════════════════════════════ PATIENT ═══════════════════════════════════════════════════════════════════════ 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. ═══════════════════════════════════════════════════════════════════════ SECTION A — CARDIOPULMONARY RESUSCITATION (when patient has NO PULSE and is NOT BREATHING) ═══════════════════════════════════════════════════════════════════════ 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. ═══════════════════════════════════════════════════════════════════════ 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. ═══════════════════════════════════════════════════════════════════════ SECTION C — ANTIBIOTICS ═══════════════════════════════════════════════════════════════════════ Order: Use antibiotics if life can be prolonged ═══════════════════════════════════════════════════════════════════════ SECTION D — MEDICALLY ADMINISTERED NUTRITION (TUBE FEEDING) ═══════════════════════════════════════════════════════════════════════ Order: Trial period of artificial nutrition Note: Oral feeding for comfort and pleasure is always offered when medically possible regardless of selection above. ═══════════════════════════════════════════════════════════════════════ 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). ═══════════════════════════════════════════════════════════════════════ 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.) ═══════════════════════════════════════════════════════════════════════ SECTION G — PATIENT OR SURROGATE SIGNATURE ═══════════════════════════════════════════════════════════════════════ _____________________________________ May 11, 2026 Patient or surrogate signature Date Printed name: Eleanor Margaret Hayes Relationship to patient (if surrogate): _____________________________ ═══════════════════════════════════════════════════════════════════════ INSTRUCTIONS FOR USE ═══════════════════════════════════════════════════════════════════════ • 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. ═══════════════════════════════════════════════════════════════════════ COPY TO PATIENT, PROVIDER, REGISTRY (where state has one) ═══════════════════════════════════════════════════════════════════════
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).