DIRECTIONS FOR HEALTHCARE PROFESSIONAL
■ Must be completed by a physician, advance practice nurse or physician assistant.
■ Use of original form is strongly encouraged. Photocopies and faxes of signed POLST forms may be used.
■ Any incomplete section of POLST implies full treatment for that section.
POLST orders are actual orders that transfer with the person and are valid in all settings in New Jersey. It is recommended that POLST be reviewed
periodically, especially when:
■ The person is transferred from one care setting or care level to another, or
■ There is a substantial change in the person’s health status, or
■ The person’s treatment preferences change.
MODIFYING AND VOIDING POLST – An individual with decision-making capacity can always modify/void a POLST at any time.
■ A surrogate, if authorized in Section E on the front of this form, may, at any time, void the POLST form, change his/her mind about the treatment
preferences or execute a new POLST document based upon the person’s known wishes or other documentation such as an advance directive.
■ A surrogate decision-maker, if authorized on this form to do so, may request to modify the orders based on the known desires of the person or,
if unknown, the person’s best interests.
■ To void POLST, draw a line through all sections and write “VOID” in large letters. Sign and date this line.
What are the speciﬁc goals that we are trying to achieve by this treatment plan of care? This can be determined by asking the simple question:
“What are your hopes for the future?” Examples include but are not restricted to:
■ Longevity, cure, remission
■ Better quality of life
■ Live long enough to attend a family event (wedding, birthday, graduation)
■ Live without pain, nausea, shortness of breath
■ Activities such as eating, driving, gardening, enjoying grandchildren
Medical providers are encouraged to share information regarding prognosis to enable the person to set realistic goals.
■ When “limited treatment” is selected, also indicate if the person prefers or does not prefer to be transferred to a hospital for additional care.
■ IV medication to enhance comfort may be appropriate for a person who has chosen “symptom treatment only.”
■ Non-invasive positive airway pressure includes continuous positive airway pressure (CPAP) or bi-level positive airway pressure (BiPAP).
■ Comfort measures will always be provided.
Oral ﬂuids and nutrition should always be offered if medically feasible and if they meet the goals of care determined by the person or surrogate.
The administration of nutrition and hydration whether orally or by invasive means shall be within the context of the person’s wishes, religion and
Make a selection for the person’s preferences regarding CPR and a separate selection regarding airway management. A deﬁned trial period of
mechanical ventilation may be considered, for example, when additional time is needed to assess the current clinical situation or when the expected
need would be short term and may provide some palliative beneﬁt.
This section is applicable in situations where the person has decision-making capacity when the POLST form is completed. A surrogate may only
void or modify an existing POLST form, or execute a new one, if authorized in this section by the person.
POLST must be signed by a practitioner, meaning a physician, APN or PA, to be valid. Verbal orders are acceptable with follow-up signature by the
physician/APN/PA in accordance with facility/community policy. POLST orders should be signed by the person/surrogate. Indicate on the signature
line if the person/surrogate is unable to sign, declined to sign, or a verbal consent is given. Remind the person/surrogate that once completed and
signed, this POLST will void any prior POLST documents.
HIPAA PERMITS DISCLOSURE OF POLST TO OTHER HEALTHCARE PROFESSIONALS AS NECESSARY
SEND ORIGINAL FORM WITH PERSON, WHENEVER TRANSFERRED