POLST in California
Physician Orders for Life-Sustaining Treatment (POLST)
The POLST is hot pink, easily viewed, usually printed on card stock, completed on both sides, and designed to help medical professionals honor the end-of-life wishes of their patients.
The completion of this form is done by the physician and patient, and documents physician orders that adhere to the patient’s wishes and treatment goals. The form is often kept on the refrigerator or the back of the front door, and emergency medical teams will look for a POLST in those places.
These forms are generally only filled out when someone is seriously ill or has a chronic disease that could take an unexpected turn of events. The form should be kept near the patient, and be readily accessible to emergency medical personnel, assisted living facility staff and other caregivers. The form should follow a patient from home, to emergency services, and to a hospital or other facility. Not all states have POLST programs in place. You may obtain a POLST from your primary or family physician.
POLST Form for download
Download California POLST form
Download the form (pdf).
POLST in other languages
Visit California POLST website for translation information.
Contact a Volunteer
If you have questions, would like to discuss advance care planning further, or need help preparing your advance directives, please contact us. A volunteer will follow up with you to find out how we can assist.
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