POLST – Physician Orders for Life-Sustaining Treatment – is a physician’s order that outlines a plan of care reflecting the patient’s wishes concerning care at life’s end.

SCAN is dedicated to ensuring that patients’ preferences at the end of life are respected. Providers are encouraged to talk with patients regarding their wishes.

The POLST form is voluntary and is intended to:

• Help you and your patient discuss and develop plans to reflect his or her wishes, and
• Assist physicians, nurses, health care facilities, and emergency personnel in honoring a person's wishes for life-sustaining treatment.
• Accompany patients across care settings.

2011 California POLST Form
In order to maintain continuity throughout California, please follow these instructions:

*** Copy or print POLST form on 65# Cover Ultra Pink card stock. ***

Mohawk BriteHue Ultra Pink card stock is available online and at some retailers, such as FedEx/Kinko’s.

Ultra Pink paper is used to distinguish the form from other forms in the patient’s record; however, the form will be honored on any color paper. Faxed copies and photocopies are also valid POLST forms.

Click here to download the 2011 California POLST Form.

California POLST form in Spanish
The Spanish form is for educational purposes only and is not a valid POLST form. The POLST form that is signed must be in English so that emergency personnel and other healthcare professionals can read and follow the orders.

Click here to download the California POLST form in Spanish.

More on POLST:
For further information on POLST, please visit the California Coalition for Compassionate Care
http://www.capolst.org/