POLST in California: what it is, who needs one and how to fill it out

When someone with a serious illness collapses at home, the people who arrive first are paramedics, and they’re trained to do everything they can. For many people that’s exactly right. For someone near the end of a long illness, it may not be what they want. In California, the form that tells emergency crews and hospitals what a seriously ill person wants is called a POLST. This note explains what it is, who should have one, and how to fill it out, using the guidance of the Coalition for Compassionate Care of California.

The short answer

• A POLST is a medical order, which makes it more than a statement of wishes. It stands for Physician Orders for Life-Sustaining Treatment.¹
• It’s for people of any age with a serious, chronic, progressive or terminal illness.¹
• The patient, or their legally recognized decision maker, signs it along with a physician, nurse practitioner or physician assistant.^1,2
• Filling one out is entirely voluntary.¹
• It doesn’t replace an advance directive. Most seriously ill people should have both.¹

What a POLST says

The form turns a person’s wishes into orders that medical teams follow. It records the kinds of treatment the person wants to receive, and the ones they don’t, for the decisions that come up in an emergency:¹

• Whether to attempt CPR if the person’s heart stops or they stop breathing
• Whether to use a breathing machine
• Whether to use other intensive treatments meant to extend life
• Whether to give artificial nutrition through a tube

Any section left blank is read as a request for full treatment.¹ Each choice is the person’s own, made with their clinician. There are no right answers on a POLST, only answers that fit the person.

Who should have one

The Coalition’s guidance is that POLST is designed for patients of any age who have a serious, chronic, progressive or terminal illness.¹ If that describes your loved one, it’s time to talk about a POLST, while they can still say what they want.

A healthy adult doesn’t need a POLST. An advance directive is the right document for someone who wants to plan ahead while they’re well.

POLST and an advance directive

They do different jobs, and they work together.¹

• An advance health care directive names the person who will make health care decisions if you can’t, and describes your values and wishes for the future. Any adult can complete one, and it doesn’t need a clinician’s signature.
• A POLST is a set of medical orders for now, for someone who is seriously ill, signed by a clinician. It travels with the person and tells emergency crews what to do today.

If you have a POLST, keep your advance directive too. The POLST says what to do in an emergency. The advance directive says who speaks for you about everything else.

How to fill one out

A POLST comes out of a conversation, not a form-filling session. Ask the doctor, nurse practitioner or physician assistant who knows the person best to talk it through. Bring the questions that matter to the person: what they’re hoping for, what they’re afraid of, what a good day looks like, and what they would not want to live through.

The clinician fills in the orders that match those wishes, and the patient or their legally recognized decision maker signs it with the clinician.^1,2 California law lets physicians, nurse practitioners and physician assistants sign the form.²

Questions to talk through first

The best POLST conversations start before anyone is holding a pen. These questions help a family hear what the person wants:

• What matters most to you right now?
• What worries you most about what’s ahead?
• If you got sicker, what would you most want to avoid?
• Where would you want to be cared for, at home or in a hospital?
• Who should speak for you if you can’t speak for yourself?

Write down the answers in the person’s own words, and bring them to the appointment.

Where to keep it

Keep the original where emergency crews will see it, such as on the refrigerator or on a table near the bed.¹ The form is printed on bright pink paper so it stands out, but it’s valid on paper of any color.¹ Photocopies and faxes are as valid as the original, and so are electronic copies like a scan or PDF.¹

Give a copy to the person’s primary doctor and to the person who would make decisions for them.¹ If the person lives in assisted living or a nursing home, make sure the staff have it in the person’s record. A bracelet or medallion can help too, since paramedics may not search a pocket or purse.¹

When to look at it again

A POLST isn’t permanent. Review it when the person’s health changes, when they move from one care setting to another, and when their wishes change.¹

The person can change or cancel it at any time, out loud or in writing. To void the form, draw a line through its orders, write VOID across it, and sign and date it. Then fill out a new one with the clinician, and share it with the decision maker and family.¹

POLST and hospice

For someone on hospice, a POLST matters most on the worst night: when something happens, the family panics, and someone calls 911. Paramedics who find a POLST can follow the person’s own choices. Hospice teams talk about POLST with families early so that night goes the way the person wanted. If you’re on hospice, call the hospice before 911 whenever you can.