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Click ‘Get Form’ to open the POLST form in the editor.
Begin by entering the patient's last name, first name, middle initial, and date of birth at the top of the form.
In Section A, select one option regarding resuscitation preferences: either 'Attempt to resuscitate' or 'Do not attempt or continue any resuscitation (DNR)'. Provide any additional instructions if necessary.
Proceed to Section B and choose from three treatment options based on whether the patient has a pulse and is breathing. Include any clarifications as needed.
In Sections C and D, indicate preferences for antibiotics and artificially administered fluids/nutrition by checking applicable boxes. Add further instructions if required.
Complete Sections E and F by discussing with relevant parties and documenting their names and contact information. Ensure all signatures are obtained where necessary.
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Because the purpose of a health care power of attorney is different from that of an advance directive, a health care agent usually do not have the authority to change or revoke the advance directives of the person they represent.
Is an advance directive the same as a POLST form?
An advance directive is a direction from the patient, not a medical order. In contrast, a POLST form consists of a set of medical orders that applies to a limited population of patients and addresses a limited number of critical medical decisions.
What is the single critical difference between an advance medical directive and a POLST document?
Advance Directives: POLSTs give specific directions about treatments during an emergency if you cannot speak for yourself. However, POLSTs do not appoint someone to speak on your behalf (surrogate or health care agent) which Advance Directives generally do.
Is a POLST different from an advance directive?
You do not need an attorney to complete the form. The form also does not have to be notarized. You do need a disinterested witness. You can find the form for the Utah Advance Healthcare Directive and instructions for completing it at .
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polst form
Provider Order for Life-Sustaining Treatment (POLST)
- This form is intended for both adult and pediatric patients. - The POLST is not an Advance Directive and does not replace it. The POLST is a Medical Order. -
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