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Physician Orders for Life-Sustaining Treatment (POLST) Sample Forms


The Physician Orders for Life-Sustaining Treatment (POLST) Paradigm program is designed to improve the quality of care people receive at the end of life. It is based on effective communication of patient wishes, documentation of medical orders, and a promise by health care professionals to honor these wishes.

A POLST Paradigm form is a brightly colored document that addresses issues such as pain management, resuscitation orders, feeding procedures, and other medical interventions. The form is completed with the approval of both the patient and the physician. It is different from an "advance directive" because it has the force of a physician's medical order and remains with patients wherever they receive care.

This tool offers sample POLST Paradigm forms from the following State programs:
  • California
  • Hawaii
  • New York
  • Oregon
  • Pennsylvania
  • Washington
  • West Virginia
  • Wisconsin
"Sample" is written across the forms to ensure that forms are not changed by anyone other than the program itself, to help maintain quality and standardization. Health care professionals can obtain specific forms from the program directly at no cost; larger orders of forms are provided by the specific program at low cost to help support their efforts.


Center for Ethics in Health Care, Oregon Health & Science University

Funding Sources

Center for Ethics in Health Care, Oregon Health & Science University

QualityTool Topic



  • Release Date: 2008
  • Original Summary: 02/2011
Disclaimer: The inclusion of a tool in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality or Westat of the tool or of the submitter or developer of the tool. Read more.

Last updated: June 18, 2014.