What does POLST stand for?

Physician Orders for Life-Sustaining Treatment. In California it’s a one-page bright pink form (or the equivalent electronic POLST eForm) signed by a physician, nurse practitioner, or physician assistant, and by the patient or the patient’s legally recognized surrogate.

Why is the POLST form pink?

California regulation requires it. The bright pink color is so that paramedics and ER staff can spot it instantly on a refrigerator, in a wallet, or on a SNF chart. The eForm doesn’t need to be pink because it’s pulled electronically, but printed POLSTs must be on the official pink stock to be honored without question.

What’s the difference between POLST and an Advance Healthcare Directive?

An AHCD is a legal document you sign while you have capacity, naming a healthcare agent and stating preferences. A POLST is a medical order, signed by a clinician, that paramedics and hospital staff follow immediately without further interpretation. AHCD says what you want. POLST tells the medical team what to do. POLST overrides AHCD in the medical moment because it’s an order; the AHCD is the underlying authority the clinician relied on when writing the POLST.

Who should have a POLST?

People with advanced illness or significant frailty. The clinical screening question is: would you be surprised if this person died in the next year? If no, a POLST conversation is appropriate. A POLST is not for healthy adults; for them, an AHCD is enough. POLST is common in hospice, skilled nursing, advanced heart failure, advanced COPD, advanced dementia, end-stage cancer, and severe frailty.

Can a family member sign a POLST for a parent who has lost capacity?

Yes, if they are the legally recognized surrogate. In California, the priority order is the healthcare agent named in an AHCD, then a court-appointed conservator with healthcare powers, then a closest available family member under the surrogate-decision-maker statute (Probate Code § 4711). The surrogate signs the patient line, and the clinician signs the clinician line. The form notes that the patient lacks capacity.

Can a POLST be revoked?

Yes, any time. The patient (if capacitated) or the surrogate can tear up the form, write VOID across it, or request a new POLST. A new POLST automatically replaces the old one. The clinician should be told so old copies in old files can be discarded.

Is there a California POLST registry?

Yes. The statewide California ePOLST Registry, administered by the Coalition for Compassionate Care of California (CCCC) in partnership with the California Emergency Medical Services Authority (EMSA), is now live and being rolled out across California regions. Paramedics, emergency departments, hospitals, and skilled nursing facilities can query POLSTs electronically using patient identifiers. Until the registry is universal in your area, the paper bright pink form remains the trusted backup: post it on the refrigerator at home, attach a copy to the patient’s chart at the SNF, and give copies to the primary physician and healthcare agent.

Who can sign a California POLST as the clinician?

California Probate Code § 4780(b) authorizes three categories of clinicians to sign POLST: a licensed physician (MD or DO), a nurse practitioner (NP), or a physician assistant (PA) acting in coordination with a collaborating physician under their California practice agreement. Registered nurses, social workers, and chaplains cannot sign POLSTs even if they facilitate the underlying conversation. The signing clinician must have either treated the patient or reviewed the medical record sufficiently to attest that the orders reflect the patient’s wishes.

Does POLST override an AHCD?

In the immediate medical moment, yes. POLST is a clinician’s order; AHCD is a patient’s directive. Paramedics and ER staff follow the POLST as they would any other physician order. But the POLST is supposed to be informed by the AHCD: the signing clinician should review the AHCD before completing the POLST so the two are consistent. If a POLST appears to contradict a recent AHCD, the medical team should pause to verify, escalate to ethics consult, and contact the healthcare agent. The AHCD is the underlying authority; the POLST is the actionable expression.

What happens if family disagrees with the POLST after a parent loses capacity?

The signing clinician should be contacted immediately. POLST can be reviewed and rewritten if family raises substantive concerns and the medical situation warrants. The legally recognized surrogate (typically the healthcare agent named in the AHCD) has authority to consent to a new POLST. If family members disagree among themselves, the AHCD-named agent prevails over other family. If there is no AHCD, the Probate Code § 4711 surrogate priority order controls. Hospital ethics committees, palliative care consults, and (in escalating cases) probate court can resolve disputes. Coalition for Compassionate Care of California publishes a family-dispute resource at capolst.org.

Is the POLST conversation reimbursed?

Yes. Medicare reimburses advance care planning under CPT codes 99497 (first 30 minutes) and 99498 (each additional 30 minutes). Medi-Cal covers the same. Commercial insurance generally pays as well. There is no patient copay for advance care planning during an annual wellness visit. Beyond reimbursement, the POLST conversation is the single highest-value 30-60 minutes of a primary care visit for a patient with serious illness, because it shapes every subsequent care decision.

POLST form: the pink medical order that overrides AHCD

What POLST is, and what it isn’t

POLST stands for Physician Orders for Life-Sustaining Treatment. In California it is a one-page bright pink form signed by a physician, nurse practitioner, or physician assistant, and by the patient or the patient’s legally recognized surrogate. Once signed, it is a medical order. Paramedics, ER staff, SNF nurses, and hospice teams follow it the same way they follow any other clinician’s order.

That’s the difference from an Advance Healthcare Directive. An AHCD is what the patient wants. A POLST is what the medical team must do. In the moment a paramedic kneels next to a 92-year-old on the floor of a memory care unit, the AHCD in the family safe is useless. The POLST taped to the inside of the refrigerator door is what gets read in the next 30 seconds.

The three core orders

California’s POLST form has three sections, in order:

Section A: CPR

Two choices for a patient with no pulse and not breathing:

Attempt resuscitation / CPR
Do not attempt resuscitation / DNR (allow natural death)

Section A applies only when the patient is in cardiopulmonary arrest. If the patient is breathing and has a pulse, Section A doesn’t apply and Section B governs.

Section B: medical interventions

Three escalating options for a patient who is alive but deteriorating:

Full treatment. Use intubation, mechanical ventilation, cardioversion, ICU care. The full toolkit of acute medicine.
Selective treatment. Treat aggressively but with limits: IV fluids, antibiotics, non-invasive ventilation (BiPAP) yes; intubation and ICU no, unless time-limited trial.
Comfort-focused treatment. Maximize comfort through symptom management. Use medication, suction, positioning, and oxygen as needed for comfort. Transfer to hospital only if comfort needs can’t be met where the patient is.

Section C: artificially administered nutrition

For patients who can’t eat by mouth:

Long-term artificial nutrition, including feeding tubes
Trial period of artificial nutrition
No artificial nutrition

Comfort care (sips of water, ice chips, hand-feeding) is always offered regardless of Section C choice.

Why POLST overrides an AHCD in the medical setting

Because POLST is an order. An AHCD is a directive that requires clinical interpretation: the doctor reads the patient’s wishes and translates them into orders. POLST is the order itself, already translated by a clinician who knows the patient’s prognosis. In an emergency, there’s no time to translate.

That said, POLST should never contradict the underlying AHCD. The clinician signing the POLST should have read the AHCD and discussed the choices with the patient (or surrogate) before signing. If the patient’s situation changes substantially, the POLST should be rewritten to reflect the new situation.

When POLST is appropriate (and when it isn’t)

The screening question used by hospice and palliative care teams is the surprise question: would you be surprised if this patient died in the next year? If no, a POLST conversation is appropriate. If yes, the AHCD alone is usually enough.

POLST is common in these populations:

Hospice patients (essentially all)
Patients in skilled nursing facilities with advanced chronic illness
Advanced heart failure, advanced COPD, end-stage renal disease without dialysis
Advanced dementia (late-stage Alzheimer’s, late-stage Lewy body, late-stage frontotemporal)
End-stage cancer
Severe frailty, multiple recent hospitalizations, recent decline

POLST is generally not appropriate for healthy adults of any age, even those who feel strongly about end-of-life choices. For them, the AHCD is the right document. POLST is meant for people whose medical reality has narrowed.

Where the POLST lives

For paramedics to honor a POLST, they have to see it. Standard California practice:

Original on bright pink paper, taped to the inside of the refrigerator door at home
Copy on file at the primary physician’s office
Copy at the SNF, ALF, or memory care facility where the patient lives, attached to the chart
Copy with the healthcare agent
If hospice is involved, the hospice team carries a copy

California is rolling out a statewide electronic POLST (eForm/eRegistry) by region. As that goes live, hospitals, paramedics, and SNFs will be able to pull the POLST electronically with the patient’s name. Until that’s universal, the bright pink paper form remains the gold standard.

How a POLST gets created

It starts with a conversation, not a form. The patient (or surrogate) meets with the physician, nurse practitioner, or physician assistant. They discuss the patient’s prognosis, the likely course of the illness, what each level of intervention would actually mean for this patient, and what the patient values. The clinician records the choices on the form. Both sign.

That conversation often takes 30 to 60 minutes. It’s reimbursed by Medicare as advance care planning (CPT codes 99497 and 99498) and is one of the highest-value uses of a primary care visit for an older or seriously ill patient. Many California hospices, SNFs, and palliative care teams initiate the POLST conversation as part of admission.

If a parent is seriously ill and there’s no POLST, ask the physician at the next visit whether a POLST is appropriate. Talk to a California-licensed elder-law attorney about how the POLST fits with the family’s overall legal plan.

The California ePOLST: a statewide registry, finally

California Probate Code § 4780 et seq. governs POLST, including authorization for an electronic form (ePOLST). The statewide California ePOLST Registry, administered by the Coalition for Compassionate Care of California (CCCC) in partnership with the California Emergency Medical Services Authority (EMSA), is now live following years of pilot in San Diego and Contra Costa. Statewide rollout proceeds region by region through 2024-2026.

How clinicians submit. Signing clinicians submit the POLST to the registry electronically at the moment of signing through the ePOLST portal or via integration with electronic health records (Epic and Cerner have implementation paths).
How paramedics retrieve. 911 paramedics, ER staff, hospitals, and SNFs query the registry by patient name and date of birth. Available 24/7.
What if there is no ePOLST. The paper bright pink form remains valid statewide and is honored as it always has been. Until ePOLST adoption is universal, both should coexist: the registered ePOLST plus a printed pink paper copy at home.
Updates. A new POLST entry supersedes the prior; old versions are retained as history but flagged superseded.

The pink-paper rule: California EMSA regulation (Title 22, CCR § 100075) specifies that the printed POLST must be on Ultra Pink 65 lb stock to be honored without verification. The ePOLST does not need to be pink because retrieval is electronic. If a POLST is photocopied onto white paper, paramedics should still honor it but may seek verification.

How to actually complete a California POLST, step by step

Confirm POLST is appropriate. Apply the surprise question. POLST is for patients with advanced illness or significant frailty, not for healthy adults.
Schedule a dedicated 30-60 minute visit with the physician, NP, or PA. This is reimbursable advance care planning under Medicare CPT 99497 and 99498.
Bring the AHCD to the visit. The clinician should review it so the POLST aligns with the underlying directive.
Discuss each section. What does CPR actually look like for this patient (frail 90-year-old with advanced dementia: chest compressions almost always cause broken ribs and rarely restore function). What does intubation actually mean (ICU stay, often delirium, often not extubated). What does comfort care actually deliver (medication for pain, anxiety, breathlessness; hand-feeding for as long as the patient enjoys).
Mark Section A (CPR). CPR or DNR.
Mark Section B (interventions). Full, Selective, or Comfort-Focused.
Mark Section C (nutrition). Long-term, trial, or none.
Both parties sign.Patient (or surrogate) signs the patient line. Clinician signs the clinician line. Print the patient’s name, the clinician’s name, and dates clearly.
Submit to the ePOLST registry if your region is live. Print the bright pink original (or have the clinic do so).
Distribute. Pink original at the bedside or on the refrigerator at home. Copies to: PCP chart, healthcare agent, hospice (if involved), SNF/ALF chart, hospital of choice, family at the bedside.
Wallet card option. The Coalition for Compassionate Care of California provides POLST wallet cards for ambulatory patients who want to carry one.
Review annuallyor whenever the patient’s condition changes.

Who can sign as the surrogate when the patient cannot

California Probate Code § 4711 establishes a priority order for surrogate decision-makers when there is no capacitated patient and no available healthcare agent:

The healthcare agent named in a valid AHCD (always first if available)
A conservator of the person appointed by a California Superior Court with healthcare decision authority
The closest available family member: spouse or domestic partner, adult child, parent, adult sibling, in that order
A close friend who is reasonably available and familiar with the patient’s values, when no family is available (added under recent amendments)

The surrogate signs the patient signature line and the form is marked to indicate that the patient lacks capacity. If the surrogate cannot be reached and the patient lacks capacity, the clinician may still complete a POLST if the patient’s wishes are known from prior conversations, the AHCD, or other clear evidence; but most California hospitals require surrogate sign-off in practice.

What it actually costs

Item	Low	Typical	High
Office visit advance care planning (Medicare CPT 99497)	$0 (during AWV)	$0 copay	Commercial copay ~$20
Hospice-initiated POLST	$0	$0	$0 (Medicare benefit)
SNF admission POLST (often included)	$0	$0	Variable
Bright pink printing (clinic-provided)	$0	$0	$10 (self-printed at FedEx)
ePOLST registry submission	$0	$0	$0
Wallet card from CCCC	$0	$0	$0

POLST is one of the few elements of California advance planning that is essentially free. The cost is the clinician’s time, which is reimbursed by Medicare and Medi-Cal.

Timeline: a typical POLST trajectory

Stage	What happens
Trigger event	Hospitalization, hospice referral, SNF admission, advanced-illness diagnosis, recent decline
Day 0-7	Care team identifies POLST as appropriate; family is informed
Week 1-2	Conversation scheduled; AHCD reviewed; family discussion among siblings and primary agent
Visit day	30-60 minute clinician visit; form completed and signed; ePOLST submitted
Within 48 hours	Bright pink original posted at bedside or refrigerator; copies distributed; SNF/ALF chart updated
Annually	POLST reviewed at care plan meeting; revised if needed
On status change	New POLST written; old form voided (write VOID across it and shred); new form distributed
At care transition	Pink form travels with patient between home, hospital, SNF, hospice; ePOLST queried in each setting

Red flags to watch for

A POLST signed without a real conversation. POLSTs handed to families at SNF admission with “sign here” are common and inappropriate. Decline to sign without a clinician discussion of what each option actually means for this patient.
POLST inconsistent with AHCD.If the AHCD says Option A (don’t prolong life if certain conditions) but the POLST says Full Treatment, the signing clinician likely did not read the AHCD. Pause and re-discuss.
POLST signed by a non-authorized clinician.RN, social worker, or chaplain signatures invalidate the POLST. California Probate Code § 4780(b) requires MD, NP, or PA.
Photocopied (white) POLST treated as authoritative. Paramedics in some California regions may pause to verify a white-paper POLST. Request a fresh pink original from the clinic; do not store only photocopies.
Old POLST not voided when a new one is written. Multiple POLSTs in circulation cause emergency confusion. The new POLST should explicitly note prior versions are voided; the family should destroy old originals.
Family pressure to upgrade a frail patient to Full Treatment without medical basis.The signing clinician must attest the orders reflect the patient’s wishes, not the family’s preferences. Ethics consultation is appropriate when there is real conflict.

What clinicians actually do at this step

The POLST conversation is one of the most important visits in late-stage care. A typical California physician, NP, or PA spends 45-75 minutes:

Pre-visit review (10-15 minutes). Reviews chart, AHCD if available, recent hospitalizations, prognosis indicators.
Patient and family conversation (30-45 minutes). Discusses prognosis honestly. Walks through what CPR, intubation, ICU care, and feeding tubes actually look like for this specific patient. Asks values questions: what makes a good day; what would be unacceptable; what experiences in the past shape the decision.
Form completion (10-15 minutes). Marks each section while the patient or surrogate watches. Reads back the choices for confirmation. Both sign.
Distribution coordination (5-10 minutes). Submits to ePOLST registry. Prints pink original. Provides copies for primary agent and chart.

A well-conducted POLST conversation reduces emergency-department visits, unwanted ICU admissions, and family conflict at end of life. Hospices, palliative care services, and skilled nursing facilities all routinely initiate POLST as part of admission; primary care physicians increasingly do so as well, particularly during Medicare Annual Wellness Visits.

Resources: Coalition for Compassionate Care of California (CCCC) publishes the current form, training materials, and family resources. California EMSA publishes regulations and clinician guidance. PREPARE for Your Care helps patients and families do the values work before the clinician visit.

Related guides and next steps

This guide explains planning options, not legal or financial advice. Talk to a California-licensed elder-law attorney about your specific situation. California Care Compass does not place referrals on Planning pages.

POLST in California: a medical order, not a wish.