Physician Orders for Life-Sustaining Treatment (POLST) Template

What Is the Physician Orders for Life-Sustaining Treatment (POLST)?

POLST is a medical order form completed jointly by patients with serious illness and their healthcare providers. Unlike advance directives that express general preferences, POLST creates actual physician orders that emergency medical services, hospitals, and nursing facilities must follow. The form addresses critical treatment decisions including cardiopulmonary resuscitation, mechanical ventilation, hospitalization, and artificial nutrition.

POLST is designed for individuals with advanced illness, frailty, or limited life expectancy who want their treatment preferences honored immediately by all healthcare providers. The form travels with you across care settings, ensuring continuity of care aligned with your goals. Without POLST, medical personnel often default to aggressive life-sustaining treatment regardless of patient preferences or likelihood of benefit.

 

 

Is This POLST Form Right for You?

You need this agreement if you're:

• Living with terminal illness or advanced chronic disease
• Elderly and frail with declining health status
• Residing in a nursing home or receiving hospice care
• Managing multiple serious medical conditions requiring frequent hospitalization
• Someone whose doctor would not be surprised if you died within a year
• Wanting specific end-of-life treatment decisions documented as medical orders

You definitely need this agreement if:

• You have a DNR preference but no formal medical order in place
• Your family members disagree about whether to pursue aggressive treatment
• You want comfort care only but fear emergency responders will intubate you
• You're transferring between healthcare facilities and need portable medical orders
• Previous hospitalizations involved unwanted aggressive interventions

 

 

Why Thousands Trust Legal GPS Templates

Save Money. Healthcare providers charge consultation fees for POLST completion. Access the template now and prepare for productive conversations with your physician.

Save Time. Understand POLST options before meeting with your doctor, allowing focused discussion on your specific preferences rather than explaining basic concepts.

Look Professional. Comprehensive template following national POLST standards ensures healthcare providers recognize and honor your documented orders across all care settings.

Keeps You Out of Court. The Healthcare Provider Signature requirement creates legally binding medical orders that eliminate ambiguity, the Review and Modification section documents ongoing care planning conversations, and the Summary of Goals section provides context that helps resolve edge cases without litigation.

 

 

 

Get Protected in 3 Simple Steps

Step 1: Secure Checkout. Complete your purchase through our encrypted payment system. Your template downloads immediately.

Step 2: Instant Download. Receive your professionally formatted POLST template compatible with Microsoft Word and Google Docs, ready for physician review.

Step 3: Complete with Your Healthcare Provider. Review treatment options, document preferences, and obtain required physician signature to create legally binding medical orders.

 

Frequently Asked Questions

Can I use this template multiple times?

Yes. You can use this template to prepare for POLST conversations with your healthcare provider. As your health status or preferences change, complete updated versions with your physician.

Is this contract legally binding?

A completed POLST signed by both you (or your healthcare decision maker) and a licensed physician, PA, or APRN creates legally binding medical orders. Healthcare providers across all settings must honor these orders.

Do I need a lawyer to complete a POLST form?

No. POLST is a medical document, not a legal document. You need a healthcare provider signature, not an attorney. However, coordinating POLST with your advance directive and healthcare surrogate designation is recommended.

What's the difference between POLST and a living will?

A living will expresses general treatment preferences and takes effect only in specific situations like terminal illness or persistent vegetative state. POLST creates immediate medical orders that apply in any medical emergency based on your current health status.

Does every state accept POLST forms?

Most states have POLST programs, though some call it MOLST, POST, or other names. Many states require use of their official state form. Check your state's POLST program for specific requirements before relying on this template.

Can I change my POLST orders after signing?

Yes. You can revoke or modify POLST at any time by voiding the current form and completing a new one with your healthcare provider, or by verbal statement to medical personnel. Updated forms automatically supersede previous versions.