Provider Orders for Life Sustaining Treatment

What is POLST?

  • POLST (Provider Orders for Life Sustaining Treatment) is a medical order form that tells others your wishes for life-sustaining treatments and is used by people who have a serious health condition. The form is on a bright lime green paper so it can be easily identified in an emergency. The orders on the POLST form are legal and are followed by paramedics and other health care providers across the entire state.
  • Social workers, chaplains, nurses and other health care professionals can complete the POLST form with you based on your desires and current medical condition.
  • POLST contains medical orders indicating your medical care preferences if you become unable to make the decisions yourself.
  • A medical doctor who has examined you and is licensed in the State of Hawaii MUST review and sign the POLST form.
  • POLST requires a signature from your doctor and from you or your identified representative, such as someone with health care power of attorney or a surrogate decision maker.

When would I need a POLST form?

  • If you have a serious health condition and you want to make decisions about life-sustaining treatment you may discuss POLST with your doctor. Your doctor can use the POLST form to write clear and specific medical orders.
  • The POLST form asks for information regarding your:
    • Medical condition(s)
    • Preferences for medical treatments, such as:
      • Attempt cardiopulmonary resuscitation (CPR)
      • Administer antibiotics and IV fluids
      • Hospitalization
      • Use of a ventilator
      • Use of a feeding tube
    • Preference for comfort care

How do I get a copy of the POLST form?

You may download the POLST Form here. You may also obtain the POLST form from your doctor or other health care providers.

Does the law require that I complete a POLST?

No. POLST is voluntary and has only been available in Hawaii since July 2009.

Does the POLST form need to be signed?

Yes. A doctor must sign the form. It then becomes a provider order that is followed by other health care professionals, including EMS personnel. The form also requires the signature of the person for whom the form is being completed or his/her health care power of attorney or surrogate decision maker.

What if I am no longer able to communicate my wishes for care?

Through an advance health care directive, you should appoint a health care power of attorney who can speak on your behalf in case you’re no longer able to speak for yourself. A doctor can complete the POLST form with your health care power of attorney or surrogate decision maker based on their understanding of your wishes.

If I have a POLST form do I need an advance health care directive (AHCD) too?

If you have a signed POLST form, it is highly recommended that you also have an advance health care directive, though it is not required. An advance health care directive is the best way to appoint a health care power of attorney. The POLST form is not the tool to appoint this person. You may obtain more information about advance health care directives on our Advance Health Care Directive page.

In what setting is the POLST form used?

The completed, signed POLST form is a provider order that will remain with you if you are transported between care settings, regardless of whether you are in the hospital, at home or in a long-term care facility. The POLST form may be used to convey your wishes to paramedics who arrive after 9-1-1 has been called.

Where should the POLST form be kept?

If you live at home, you should keep the original green POLST form in a location where it can easily be seen. The ideal place is on your refrigerator where EMS personnel will look for it first. Other visible places could be the back of the bedroom door, on a bedside table, or in your medicine cabinet. If you reside in a long-term care facility, your POLST form may be kept in your medical chart along with other medical orders.

Why is the POLST form bright green?

The form is brightly colored so it can easily be found when needed and will be honored by health care providers, including EMS personnel. However, a black & white copy of the completed form is still valid and legal.