POLST – Physician Orders for
Life-Sustaining Treatment
POLST (Physician Orders for Life-Sustaining Treatment) is a form that states what kind of medical treatment patients want toward the end of their lives. Printed on bright pink paper, and signed by both a doctor and patient, POLST helps give seriously ill patients more control over their end-of-life care.
*POLST Trainers and Physician Champions may access the POLST Education Website here - you will need your login and password.
California POLST Form
English [PDF]
| Armenian [PDF] | Chinese (Traditional) [PDF] |
| Farsi [PDF] | Chinese (Simplified) [PDF] |
| Korean [PDF] | Hmong [PDF] |
| Russian [PDF] | Pashto [PDF] |
| Tagalog [PDF] | Spanish [PDF] |
| Vietnamese [PDF] |
To request a Braille POLST form, contact info@coalitionccc.org or (916) 489-2222. POLST forms can be ordered from Med-Pass.
Revised POLST Form Effective April 1, 2011
Changes to the California POLST Form were approved by the statewide POLST Task Force and the Emergency Medical Services Authority Commission. The revised form went into effect on April 1, 2011. Previous versions of signed POLST forms remain valid. For a summary of the changes to the form, click here.
Additional POLST resources are also available in bulk.
Videos
Related videos, click on the video thumbnail below to watch. Video will open in a new window so please allow pop-ups from this site.
POLST at Work in California
This 12-minute video provides a detailed look at the POLST form and how it works in a community as a patient is transferred between health care settings. The video is designed for health care providers, but can also be helpful for consumers wishing to learn more about POLST. The video is adapted from Oregon’s POLST at Work video.
POLST: Honoring Patients’ Wishes for Treatment
CA POLST is helping honor patients wishes for treatment.
POLST: Having the POLST Conversation
A demonstration of the doctor/patient POLST conversation.
Honoring the Wishes of the Spanish
Speaking Patient and Family
English version | Spanish version [Real Media File]This 19-minute video from Oregon’s POLST program is designed for the Spanish-speaking community and addresses the important role of bilingual family members and the use of an interpreter, as well as how culture and spirituality can play an important role during end-of-life care. Designed for health care providers, patients and family members.
