POLST and DNR Forms

POLST – Physician Orders for Life-Sustaining Treatment

Physician Orders for Life-Sustaining Treatment (POLST) is a form that gives seriously-ill patients more control over their end-of-life care, including medical treatment, extraordinary measures (such as a ventilator or feeding tube) and CPR. Printed on bright pink paper, and signed by both a patient and physician, nurse practitioner or physician assistant, POLST can prevent unwanted or ineffective treatments, reduce patient and family suffering, and ensure that a patient's wishes are honored.

The POLST form should be clearly posted or maintained near the patient.

Further information on the POLST may be found at http://capolst.org/

To download a POLST Form please click on the image of the POLST form below.



DNR - Do Not Resuscitate

The Prehospital Do Not Resuscitate (DNR) Form is an official State document developed by the California EMS Authority, in concert with the California Medical Association and emergency medical services (EMS) providers, for the purpose of instructing EMS personnel regarding a patient's decision to forgo resuscitative measures in the event of cardioplumonary arrest. Resusciative measures to be withheld include chest compressions (CPR), assisted ventilation (breathing), endotracheal intubation, defibrillation, and cardiotonic drugs (drugs which stimulate the heart). The form does not affect the provision of life sustaining measure such as artificial nutrition or hydration or the provisions of other emergency medical care, including treatment for pain, difficulty breathing, major bleeding, or other medical conditions.

The DNR must be signed by the patient or by the patient's legally recognized health care decisionmaker if the patient is unable to make or communicate informed health care decisions. The patient's physician must also sign the form, affirming that the patient/legally recognized health care decisionmaker has given informed consent to the DNR instruction.The DNR form should be clearly posted or maintained near the patient.

For further information on the DNR Form (including the pdf form) please refer to the California Emergency Medical Services Authority webpage found on the following link.


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