Honoring POLST in Private Homes and Residential Care Homes

If you own or work in a residential care facility, or care for clients in private homes, you may encounter people who have POLST forms. This video provides you with the “what, when, where and how” the POLST form is applied.

There is a lot of confusion about how adult family home providers should deal with POLST form implementation. In this post, you’ll learn the answers to essential points adult family home providers need to know about handling emergencies and working with POLST forms.

The video was created by at team of experts convened by the WSMA, the Washington State POLST Task Force and the Washington State Department of Social and Health Services.

What is the POLST form?

POLST stands for “Physician Orders for Life-Sustaining Treatment. ” The form is a medical order that allows individuals with a serious illness or frailty to summarize their wishes regarding life-sustaining treatment.

The form offer more security for the patient and physician that the patient’s wishes will be carried out.

What is main purpose of the POLST form?

The form accomplishes two major purposes: a) It is portable from one care setting to another, and b) It translates wishes of an individual into actual physician orders.

How is the POLST form used?

In adult family homes, the form should be the first document in the clinical record. Another common place to keep this form is on the resident’s bedroom door, usually taped on the inside. It will be recognized by emergency personnel as orders to be followed.  This form should be recognized as physician orders to be implemented, just as any other physicians’ orders.

How should the form be transferred to another?

The POLST form should remain with the resident and be transported between care settings, regardless of whether it’s a hospital, home or long-term care facility. You may wish to keep a duplicated copy in the resident’s medical record upon discharge. When calling 911, i like to make a copy for them and keep the original in the resident’s file. Upon the resident’s return to your AFH, you’ll want to make sure no changes were made to the POLST form during the hospital stay.

What’s the difference between a POLST form and advance directives?

Although similar, an advance directive (also called a Living Will) is a legal document frequently used in estate planning, which addresses issue relative to artificial life support.

The POLST form is a clear and quick and clear way to direct medical professionals and EMS personal to perform CPR or not, and when to use antibiotics.

While advance directives can be very helpful in determining end-of-life decisions, they are not required for having a POLST form.

Provider Resources

Download the POLST form. This downloadable POLST form can serve as your master copy. It should be printed on 8-1/2″ x 11″ green card stock, front and back. The “official color” is Astrobrights terra green (smooth finish), 65 lbs.

The most recent version of the POLST form is 2014 (it’s marked “Revised 4/2014”). Previous versions of the form will continue to be honored.

Download the master copy POLST form for print.

Educational resources for patients in English and Spanish

You can download a tri-fold brochure designed to inform and instruct residents and families. It contains an overview of and frequently asked questions about the POLST form.

  • Click here to download the English patient brochure.
  • Click here to download the Spanish patient brochure.


Joseph Spada
Joseph Spada

Adult Family Home Consultant, geriatric nurse, owner of Spada Care Homes, Ohana Hale Senior Living, and Savanna Healthcare; DSHS instructor of the AFH Administrator Training; speaker; author.

Leave a Reply

Your email address will not be published.