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Forms

A POLST is a physician-signed order form which communicates and puts into action treatment preferences when a patient is near the end of their life. The Virginia POST form was modeled after the Oregon POLST form which has been in use for more than 20 years.

POLST is for those with a terminal illness, or those dealing with a chronic progressive illness, like advanced heart or lung disease or cancer, that has spread.  Those who are frail and elderly may benefit from a POLST, as well.

The POLST form should be completed only after the patient (or, if the patient lacks capacity, the patient’s health care agent) has an advance care planning discussion with a physician or a trained POLST Advance Care Planning Facilitator (ACPF) under the direction of a physician.

Patients and families interested in creating a POLST form should do so through their health care provider. 

 

Health care professionals or organizations interested in POLST may contact us for further information.

 

Sample National POLST Form (with Virginia's information in the state-specific box on page 2), recently adopted for use in our state.

Sample Virginia POST Form  

 

These are sample forms only and not intended for clinical use. Official forms must be obtained from your physician. Physicians: Please note that not all regions of Virginia have implemented the POLST/POST program. If POLST/POST forms are not available in your area yet, we would love to work with you to implement POLST in your community or facility.

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