To fill out the Minnesota POLST form, you work through it with a Minnesota-licensed physician, advanced practice registered nurse, or physician assistant who signs it as a medical order. The form has three treatment sections — CPR, medical treatments, and artificially administered nutrition — plus patient identification fields and a provider signature block. You cannot complete it on your own, because a POLST is a clinical order that requires a face-to-face conversation with a qualified provider who can assess your condition and explain what each choice means in your situation.
Who the Form Is For
The POLST is designed for people with advanced serious illness or frailty whose healthcare provider would not be surprised if they died within the next year or two. That “surprise question” is the clinical threshold providers use to decide whether the form is appropriate.1Minnesota Medical Association. POLST Minnesota: Frequently Asked Questions It is most common for patients in long-term care, people receiving hospice, and those managing terminal diagnoses at home.
If you are relatively healthy and want to document preferences and name someone to speak for you, a Minnesota health care directive is the right tool instead; a POLST does not appoint a surrogate decision-maker.2Minnesota Board on Aging. Advance Directives
Where to Get the Blank Form
The official form is a free PDF download from the Minnesota Medical Association3Minnesota Medical Association. POLST and is also hosted by the Minnesota Department of Health.4Minnesota Department of Health. Minnesota Provider Orders for Life-Sustaining Treatment You can also get a copy from your physician, a hospital social worker, or a long-term care facility’s care planning team. Bringing a blank form to an appointment is a reasonable way to open the conversation.
Patient Identification at the Top
At the top of the form, enter the patient’s last name, first name, middle initial, and date of birth.4Minnesota Department of Health. Minnesota Provider Orders for Life-Sustaining Treatment Accuracy here matters. In an emergency, mismatched identifiers can delay care or make providers question whether the orders belong to the patient in front of them.
Section A: Cardiopulmonary Resuscitation
Section A applies only when the patient has no pulse and is not breathing. You pick one of two orders:
- Attempt Resuscitation / CPR. Choosing this requires also selecting Full Treatment in Section B.
- Do Not Attempt Resuscitation / DNR (Allow Natural Death). When the patient is not in cardiac arrest, providers follow Section B instead.
If you choose DNR, EMS will not perform chest compressions, defibrillation, or intubation for cardiac arrest.4Minnesota Department of Health. Minnesota Provider Orders for Life-Sustaining Treatment
Section B: Medical Treatments
Section B governs care when the patient still has a pulse or is breathing but needs treatment. Pick one level:
- Full Treatment. Intubation, advanced airway interventions, and mechanical ventilation. Transfer to a hospital or intensive care unit as indicated.
- Selective Treatment. Antibiotics, IV fluids, and cardiac monitoring, but no intubation or mechanical ventilation. Less invasive airway support such as CPAP or BiPAP may be considered. Transfer to a hospital if needed, but generally avoid the ICU.
- Comfort-Focused Treatment (Allow Natural Death). Relieve pain and suffering through medication, positioning, wound care, and similar measures. Oxygen and suction as needed for comfort. No transfer to a hospital for life-sustaining treatment.
All three levels include comfort care. The difference is how aggressively providers intervene beyond comfort.1Minnesota Medical Association. POLST Minnesota: Frequently Asked Questions
Section C: Artificially Administered Nutrition
Section C addresses feeding tubes. The choices are long-term artificial nutrition by tube, a defined trial period of artificial nutrition by tube, or no artificial nutrition by tube. Whichever you select, the form directs providers to offer food by mouth if feasible.4Minnesota Department of Health. Minnesota Provider Orders for Life-Sustaining Treatment The trial-period option lets a patient try tube feeding for a set duration to see whether it improves comfort or function, with a plan to reassess at the end.
Signatures That Make It Valid
A physician (MD or DO), APRN, or PA licensed in Minnesota must sign the form for it to be a valid medical order.1Minnesota Medical Association. POLST Minnesota: Frequently Asked Questions The provider’s name, title, phone number, and the date prepared are all required fields.4Minnesota Department of Health. Minnesota Provider Orders for Life-Sustaining Treatment
The patient or a surrogate is strongly encouraged to sign the form, but the form is valid without that signature.5Minnesota Department of Health. MN POLST Registry Report Key Findings and Recommendations A surrogate can be a court-appointed guardian, a health care agent named in a health care directive, or a person the provider believes best knows the patient’s wishes. Signing it reinforces that the orders came out of a real conversation.
Keeping the Form Where It Will Be Found
A POLST only works if first responders can find it. Patients at home are encouraged to keep the original somewhere visible: on the front of the refrigerator, clipped to a bedside table, or in a plastic sleeve near the main entrance. Healthcare facilities scan the form into the electronic medical record so staff can access it digitally. When a patient transfers between settings, the original paper form should travel with them.6Minnesota Medical Association. POLST Minnesota: Information for Patients and Family Members That portability across care settings is what distinguishes a POLST from other advance care planning documents.3Minnesota Medical Association. POLST
Changing or Revoking the Form
You can revoke a POLST at any time, verbally or in writing. If your health improves, your goals of care change, or you simply change your mind, the existing form can be replaced. You cannot amend a POLST by crossing out lines or writing in the margins. A new form must be completed and signed by a licensed provider.6Minnesota Medical Association. POLST Minnesota: Information for Patients and Family Members
When a new form replaces an old one, notify every provider who might have a copy so the outdated version is removed from medical files. The old form should be clearly voided or destroyed to prevent confusion during a future emergency. Review the POLST at regular check-ups or whenever a significant health change occurs so the orders stay aligned with what you actually want.3Minnesota Medical Association. POLST