Arizona POLST (Physician Orders for Life-Sustaining Treatment) Form

📄 National POLST Form – Arizona Version (English)

❓ What Is a POLST Form?

A POLST (Portable Medical Orders) form:

• Specifies your wishes about CPR, breathing machines, intensive care, and other emergency treatments

• Is intended for people with serious illness or frailty

• Must be signed by a healthcare professional to be valid

• Travels with you across healthcare settings—home, hospital, nursing facility

Think of it as an “active medical order” that supports end-of-life or critical care decisions right now—not just in the future.

✍️ Step-by-Step Instructions

Section A: Cardiopulmonary Resuscitation (CPR)

What it asks: Choose one of two options:

• Attempt Resuscitation/CPR: If your heart stops, EMS will attempt CPR, defibrillation, and advanced cardiac life support.

• Do Not Attempt Resuscitation (DNR): EMS will not perform CPR or try to restart your heart or breathing.

Helpful Tip: This choice applies only if your heart and breathing stop. If you're unsure, speak with your doctor or healthcare provider.

Section B: Medical Interventions

What it asks: Choose one of three levels of medical treatment:

1. Full Treatment All available treatments including intubation, mechanical ventilation, ICU care

2. Selective Treatment Hospital treatment and interventions like IV fluids or antibiotics, but no ICU care or intubation

3. Comfort-Focused Treatment Focus on relieving pain and symptoms, not life-prolonging procedures

You can also add specific instructions in the space provided.

Helpful Tip: Use this section to balance your comfort, values, and quality of life. Be as specific as you want.

Section C: Artificially Administered Nutrition

What it asks: Indicate your preferences for feeding tubes:

• Long-term nutrition by tube

• Trial period only

• No artificial nutrition

You can include additional instructions.

Helpful Tip: Feeding tubes are often used in prolonged unconscious states or advanced illness. If comfort and quality of life are more important to you, choose accordingly.

Section D: Information & Signatures

What it asks:

• Name and contact info of the person the form is for

• Signature of a healthcare professional (required)

• Signature of the individual or representative (optional in AZ but recommended)

• Date

Helpful Tip: The POLST is not valid unless signed by a physician, nurse practitioner, or physician assistant. They can complete this form with you during a medical visit.

📥 After You Complete the Form

1. Make Copies and Share Keep the original in an easily accessible place—on your fridge or in a medical file. Share copies with:

   • Family members

   • Caregivers

   • Your primary care physician

   • Assisted living or long-term care staff (if applicable)

2. Register the Form (Optional) Arizona has a voluntary Health Care Directives Registry. You can upload your POLST there for healthcare providers to access: 🔗 azhdr.org

3. Review and Update as Needed Update this form if your health condition or treatment preferences change. A new version must be signed again by a healthcare provider.

💡 When Should You Use a POLST?

You should consider using a POLST if:

• You have a serious illness (e.g. cancer, advanced heart/lung disease, dementia)

• You are medically frail or over the age of 65 with complex health needs

• You want to avoid unwanted medical interventions

• You want to be sure your care wishes are honored in an emergency

If you're healthy, a living will is usually more appropriate than a POLST.

🛠️ Need Help?

We can help you fill this out with your doctor or care team—or review your medical situation to decide if this form is right for you. You don’t have to do this alone.