POLST form - New Jersey Hospital Association 2025

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The document outlines the New Jersey Practitioner Orders for Life-Sustaining Treatment (POLST), which is a medical order sheet that reflects a person's healthcare preferences regarding life-sustaining treatments based on their current medical condition and wishes. It includes sections for goals of care, medical interventions, artificial nutrition, cardiopulmonary resuscitation (CPR), and airway management. The POLST form must be completed by a physician or advanced practice nurse and is valid across all healthcare settings in New Jersey. It emphasizes the importance of dignity, respect, and the ability to modify or void orders as needed.

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Click ‘Get Form’ to open the POLST form in the editor.
Begin by entering the person's name and date of birth at the top of the form. This information is crucial for identifying the individual.
In Section A, outline the goals of care by selecting options that reflect the individual's wishes regarding treatment and quality of life.
Proceed to Section B, where you will choose medical interventions. Indicate preferences for hospital transfer and treatment types based on comfort needs.
In Section C, specify preferences regarding artificially administered fluids and nutrition. Ensure these align with the person’s desires.
Section D requires decisions on CPR and airway management. Clearly mark your choices based on the individual’s health status.
Complete Section E if applicable, designating a surrogate decision maker who can modify orders if necessary.
Finally, ensure that a physician or APN signs Section F to validate the document. This step is essential for compliance.

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Versions	Form popularity	Fillable & printable
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2012	4.3 Satisfied (122 Votes)

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Is a DNR the same as a CPR directive?

A Do Not Resuscitate (DNR) order is another kind of advance directive. A DNR is a request not to have cardiopulmonary resuscitation (CPR) if your heart stops or if you stop breathing. (Unless given other instructions, hospital staff will try to help all patients whose heart has stopped or who have stopped breathing.)

What is an NJ POLST form?

This form, signed by a patients attending physician, advanced practice nurse or physicians assistant, provides instructions for health care personnel to follow for a range of life-prolonging interventions.

How is POLST different from DNR?

A POLST is more comprehensive than a Do Not Resuscitate order. A DNR is a stand-alone document that tells emergency medical personnel whether to perform CPR if your heart and breathing stop and you are unresponsive. A POLST includes your instructions about whether or not to perform CPR, but it doesnt stop there.

What is the difference between a POLST and a MOLST?

MOLST and POLST are two acronyms defining medical orders. The MOLST is the Medical Orders for Life-Sustaining Treatment and the POLST is the Physician Orders for Life-Sustaining Treatment. Theyre both the same thing, but in different states they call them by those two different names.