FAQ:

The POLST Form

What is POLST?
POLST stands for Provider Orders for Life Sustaining
Treatment. It is a signed medical order form that
communicates the patients end-of-life health care wishes
to other health care providers during an emergency.
How does a POLST form differ from an Advance
Directive?
The POLST form serves as a tool by which providers
can discuss end-of-life treatment options with patients
already diagnosed with serious illnesses. Patients have an
opportunity to ask the provider detailed questions about
treatment options available to them, and thereby make
informed decisions. Once a treatment plan has been
selected by the patient, the provider will sign the form as a
medical order, which can then be used by EMS personnel
and other health care professionals during an emergency.
The advance directive is a document that is lled out and
signed by a patient. The form is often times completed
prior to the patient having a serious illness. It is intended
to communicate the patients wishes to a physician or
other health care provider, as well as the patients family
and caregivers, should he/she lose the ability to make
independent heath care decisions.
Who Should Have a POLST form?
Patients with serious health conditions who need to make
decisions about life sustaining treatment in advance of
medical emergencies should have a POLST form. The form
is recommended even for patients who have an advance
directive, because it provides greater detail as to the
provision of for the patients emergency care.
Where is a POLST form stored?
A POLST form is intended to travel with the patient
between care settings including the patients home, long-
term care facility or hospital. It should be kept in a place
where emergency responders can nd it (for example, on
the refrigerator door, if the patient lives in a house, or in
the chart of a nursing home patient). Ideally, this form will
also be kept as part of a patients electronic medical record.
How Often Should a POLST Form be Reviewed and/or
Replaced?
The POLST form should be reviewed each time the patient
is transferred from one care setting or level to another, or
when there is a substantial change in the patients health
status. A new POLST form should be completed when the
patients treatment preferences change.

Who Completes and Signs the POLST form?

A POLST form can be completed by a patients health care
provider after he/she discusses life-sustaining treatment
options with the patient, and the patient selects a
treatment plan. Once the form is lled out, the provider
signs and dates the form. Because the POLST form is a
medical order, the form must be signed on the front side by
a health care provider for it to be followed by other health
care professionals. The form may also be signed on the
back side by other health care professionals, the patients
guardian, health care agent or other surrogate contact
person, and by the patient. Note: Although the patients
signature is not required for medical orders, the MMA
encourages providers to obtain the patients signature in
Section E when lling out the POLST form.

Adult Day Services Policies and Procedures Manual

A Product of LeadingAge Minnesota October 2016
05-034.16
Last Updated January 2010
 How can a POLST form be voided?
A POLST form can be voided:
1. At the direction of the patient, the provider is
instructed to revoke the POLST form; or
2. At the direction of the patient, the provider lls out
a new and revised POLST form and signs it with the
current date; or
3. The patient draws a line through the POLST form and
writes VOID in large letters on it; or
4. The patient tears, burns or otherwise destroys the
POLST form.

Where can I nd directions for the individual sections

of the POLST form?
Directions on how the POLST form is to be lled out
are located on the back of the form. Providers should
familiarize themselves with the directions prior to using the
form with patients.

Why are there two versions of the POLST form

available on the MMA website?
The version of the form that bears the MMA logo was
the version that was approved by the interdisciplinary
work group that developed the form, the MMA Board of
Trustees, and the Emergency Medical Services Regulatory
Board (EMSRB) in 2009. The version of the form that does
not bear the MMA logo may be tailored to suit the specic
needs of some providers patients and/or organizations
policies. Note however, that altering the form may require
the approval of the EMSRB before it is recognized by rst
responders at the scene of an emergency.

Note: For purposes of this FAQ, the term patient is also intended
to include the patients health care agent or surrogate decision maker.
The term provider includes the patients physician, nurse practitioner
or physician assistant .
1. Physician assistants may sign a POLST form only if they have been
delegated the authority by their supervising physician.
2. A health care professional other than physicians, nurse practitioners
and physician assistants may discuss treatment options and ll out the
form with the patient, however, a physician, nurse practitioner or a
physician assistant must sign the front of the form for it to be valid.

Adult Day Services Policies and Procedures Manual

A Product of LeadingAge Minnesota October 2016
05-034.16

Last Updated January 2010