How to Complete the Texas POLST Form: Sections, Signatures, and Storage

To complete the Texas POLST form — the Physician Orders for Life-Sustaining Treatment — you sit down with your physician for a shared decision-making conversation, work through each section of the form together, and sign it alongside your physician. The form is not a do-it-yourself document. And if you choose “No CPR,” you also need a separate Out-of-Hospital Do-Not-Resuscitate order, because Texas EMS personnel are legally required to honor only the OOH-DNR, not the POLST.¹

Who the Form Is For

POLST is designed for people with a serious illness, advanced frailty, or a condition where the physician would not be surprised if the patient died within the next year. It translates current care preferences into active physician orders that travel between settings.

If you are generally healthy and planning ahead, POLST is not the right tool. A Directive to Physicians (living will) or a Medical Power of Attorney is what you want. Those forms are available through Texas Health and Human Services and carry full statutory recognition under Texas Health and Safety Code Chapter 166.² POLST supplements those documents; it does not replace them, and the choices across all your advance care documents should be consistent.

Where To Get the Form

The Texas POLST form is not on the Texas Health and Human Services advance directives page, which hosts the state’s other recognized forms. It is available through the Texas POLST Toolkit, which includes a sample form on its last page along with a completion guide.³ Your physician’s office or a palliative care team can also provide a blank form.

Filling Out Each Section

The form is completed during a conversation with your physician, who reviews your medical situation, prognosis, and preferences before writing the orders. Each section below records a specific decision.

Patient Information

The top of the form captures your name, date of birth, and identifying details. Emergency responders use this to confirm the form belongs to you before acting on it.

Section A: Cardiopulmonary Resuscitation Orders

Section A applies only when you have no pulse and are not breathing. You choose one of two options:

Yes CPR: emergency personnel attempt resuscitation, including chest compressions, defibrillation, and mechanical ventilation.
No CPR (DNAR): Do Not Attempt Resuscitation. No CPR efforts are initiated.

If you choose “Yes CPR,” you must also choose “Full Treatments” in Section B. You cannot request resuscitation while also limiting treatment intensity.⁴ If you choose “No CPR,” your physician must complete a separate Texas Out-of-Hospital DNR form. That step is not optional; it is the only DNR document Texas EMS is legally required to honor.

Section B: Initial Treatment Orders

Section B covers what happens in an emergency when you still have a pulse or are still breathing. You pick one of three levels:

Full Treatments: all appropriate medical and surgical interventions to sustain life, including intensive care, intubation, and mechanical ventilation.
Selective Treatments: appropriate medical treatments while avoiding burdensome interventions. Generally no intensive care and no resuscitation, but may include IV fluids, antibiotics, and non-invasive breathing support like CPAP or BiPAP.
Comfort-Focused Treatments: treatments aimed at relieving pain and suffering. No transfer to a hospital for life-sustaining treatment. Focus is entirely on comfort and dignity.

“Selective Treatments” covers a wide range. The conversation with your physician is where you pin down exactly what falls inside and outside that category for your situation.

Section C: Additional Orders or Instructions

This is a free-text area for preferences beyond the Section B categories, such as blood products, dialysis, or transfer to a specific facility. EMS protocols may limit what emergency responders can act on here, so orders in this section are most useful for hospital and facility staff.⁴

Section D: Medically Assisted Nutrition

Section D covers artificially administered nutrition through feeding tubes or IV lines. You choose among long-term surgical feeding (such as a gastrostomy tube), short-term non-surgical feeding (such as a nasogastric tube), or no artificial nutrition. A “no decision” option lets you revisit the topic later. Regardless of what you select, offering food and drink by mouth remains appropriate if you can swallow safely and want to eat.

Signatures That Make the Form Valid

Two signatures are required.

Section E is signed by you or your legally recognized representative to confirm the orders reflect your conversation with the physician. A Medical Power of Attorney agent or another surrogate should note the basis of their authority and print their full name alongside the signature.³

Section F is signed by the physician, who also prints their full name and provides their license number. In Texas, only a physician can sign the POLST. The toolkit states that Texas does not recognize supervising roles that would allow a physician assistant or nurse practitioner to sign.³ The “Supervising Physician Signature” line on the national-format form can be ignored in Texas.

Why You Also Need an Out-of-Hospital DNR

This is the piece most people miss. Under Texas Health and Safety Code Section 166.102, EMS personnel are required to honor only a properly executed Out-of-Hospital DNR order or a prescribed DNR identification device. They have no duty to review, interpret, or honor any other written directive, including a POLST.¹

If you selected “No CPR” on your POLST, you need a completed OOH-DNR to make that choice enforceable when paramedics arrive. The OOH-DNR has its own execution requirements. Either the patient signs before two qualified witnesses, at least one meeting the independence criteria under Section 166.003, or the signature is acknowledged before a notary public.⁵ The attending physician must also sign and document the order in the patient’s medical record. The form is available from the Texas Department of State Health Services EMS/Trauma Systems division.

Without the OOH-DNR, Texas law presumes consent to treat in an emergency. A POLST alone does not override that presumption for EMS, no matter how clearly it says “No CPR.”⁶

Storing and Transporting the Form

POLST forms are traditionally printed on bright green (often called lime-green) paper so healthcare workers can spot them quickly. The color is convention, not law. A white photocopy completed and signed correctly is equally valid. Still, a brightly colored sheet taped to the refrigerator or placed near the head of the bed is far easier for a first responder to see than a white page in a folder.

Keep the original in a visible, consistent location. Provide copies to your primary care physician, specialists, and the medical records departments of hospitals or facilities where you receive care. When you move between settings, the physical form should travel with you. Digital copies in an electronic health record help with continuity, but the paper document is what a paramedic or on-call nurse looks for in real time.

Changing or Voiding the Form

POLST orders are always voluntary. You can void your form at any time. Because it is a medical order signed by a physician, you cannot simply edit the form yourself. Tell your physician if your preferences change, and a new form should be completed to replace the old one. Destroy or clearly mark the previous form as void to prevent confusion.

A legally recognized surrogate may also request changes, but any modification should involve a conversation with the physician. When a POLST and an advance directive conflict, care should follow the most recently executed document until the patient or surrogate can clarify their wishes. Reviewing your existing advance directives during the POLST conversation is the way to catch and resolve inconsistencies before they cause problems in a crisis.³

Legal Limits To Keep in Mind

Texas does not currently have a statute that specifically establishes or regulates POLST. The Texas Advance Directives Act under Chapter 166 governs living wills, Medical Powers of Attorney, and Out-of-Hospital DNR orders, but does not mention POLST.² The Texas Medical Association has said that instituting POLST fully will require legislative change and that, without statutory backing, the form does not provide the same liability protections to physicians that the OOH-DNR does.⁶

Inside hospitals, nursing facilities, and home health settings, physicians and nursing staff routinely follow POLST orders as part of coordinated care. The gap is with EMS. Paramedics responding to a 911 call operate under state law that directs them to the OOH-DNR and nothing else. Treat POLST as a complement to your statutory advance directives, not a substitute for them. The POLST captures a broader range of treatment preferences than the OOH-DNR can, and the OOH-DNR provides the legal enforceability the POLST currently lacks in emergency settings.

1
State of Texas. Texas Health and Safety Code 166-102 – Physicians Do-Not-Resuscitate Order
2
State of Texas. Texas Health and Safety Code Chapter 166 – Advance Directives
3
National POLST. Texas POLST Toolkit
4
National POLST. National POLST Form Guide
5
State of Texas. Texas Health and Safety Code 166-082 – Out-of-Hospital Do-Not-Resuscitate Order
6
Texas Medical Association. End-of-Life Care Form