How to Get and Complete the Washington State POLST Form

The Washington State POLST form is a bright green, physician-signed medical order that tells emergency responders and clinicians which life-sustaining treatments you want and which you want withheld. You get it from the Washington State Medical Association at wsma.org/POLST, complete it in conversation with a qualifying clinician, sign it together, and keep the original somewhere visible in your home. It is meant for people who are seriously ill or in very poor health, not for healthy adults doing routine planning.

Who the Form Is Meant For

A POLST is designed for people whose health has declined to the point where emergency interventions like CPR might be ineffective or at odds with how they want to spend their remaining time.¹ A clinician will typically raise it after a significant diagnosis, a noticeable drop in physical function, or admission to a long-term care facility.

If you are generally healthy, you do not need one. A standard advance directive or durable power of attorney for health care is the right document for you.² The advance directive captures your broader values. The POLST converts those values into specific orders that paramedics can act on in seconds.

Where to Get the Form

The official form lives at wsma.org/POLST, maintained by the Washington State Medical Association.² The Department of Health website links to the same document. Hospitals, hospice agencies, and many primary care offices keep blank copies on hand and will provide one at an appointment.

Print the form on bright green paper. First responders are trained to scan for that color when they walk into a home.¹ A form on white paper is still legally valid, but it is easier to miss during a 911 call. If you are printing at home, use the brightest green stock you can find.

How to Fill Out Each Section

The form covers four treatment areas. Think through your preferences before your appointment, because any section you leave blank defaults to full treatment for that category.³

Section A: Cardiopulmonary Resuscitation

This section applies only when your heart has stopped and you are not breathing. You pick one of two options: attempt CPR, or do not attempt resuscitation and allow natural death (DNAR).³ If you choose CPR, you must also choose full treatment in Section B, because there is no clinical scenario where a team restarts your heart and then withholds further intervention.⁴

Section B: Medical Interventions

Section B applies when you still have a pulse or are still breathing but face a serious medical event. You choose one of three levels:

Full Treatment: all available interventions, including transfer to intensive care, intubation, and mechanical ventilation.
Limited Additional Interventions: antibiotics, IV fluids, and cardiac monitoring, but no intubation or mechanical ventilation. This fits people who want treatment but not a ventilator.
Comfort Measures Only: pain management, symptom relief, and keeping you comfortable, with no hospital transfer unless needed for comfort.

Any of these can be paired with a DNAR order in Section A.⁴ That combination is common. Many patients want treatment for manageable problems like infections but do not want chest compressions if their heart stops.

Section D: Nutrition, Antibiotics, and Additional Orders

For artificially administered nutrition, your choices are no tube feeding, a trial period to see whether you recover enough to eat on your own, or long-term tube feeding.³ Whichever you pick, staff will always offer food and liquids by mouth if you can swallow safely.

A separate line covers antibiotics, from full use to symptom-relief approaches. The form also leaves space for additional orders, such as instructions about dialysis or implanted cardiac devices. If your situation involves treatments the standard checkboxes do not cover, your clinician can write specific instructions there.

Who Has to Sign

A POLST is not valid until both you (or your surrogate) and a qualifying clinician sign it. The clinician must be a physician (MD or DO), a nurse practitioner (ARNP), or a certified physician assistant (PA-C).⁴ Without both signatures, the document is a statement of preferences, not an enforceable order.³

The conversation with your clinician is a required part of the process. Their signature confirms the orders match your medical condition, your known preferences, and the best available information about your prognosis. Printing the form at home and filling in every checkbox is fine, but you still need a face-to-face or telehealth discussion before any licensed professional will sign.

When a Surrogate Signs

If you lack the capacity to make your own medical decisions, a surrogate can sign for you. Washington law sets a priority order:⁵

Court-appointed guardian
Agent named in a durable power of attorney for health care
Spouse or state-registered domestic partner
Adult children
Parents
Adult siblings
Adult grandchildren who are familiar with you
Adult nieces and nephews who are familiar with you
Adult aunts and uncles who are familiar with you
A close adult friend who has shown special care and concern, is familiar with your values, and is not a paid caregiver or employee of a facility where you receive care

The highest-ranking available person on the list has authority. A surrogate’s decisions should reflect what you would have wanted based on previously expressed wishes. If those wishes were never documented, the surrogate decides based on your best interest.⁶

Where to Keep It

The bright green original stays with you at all times.¹ At home, put it somewhere EMS personnel know to look: the front of the refrigerator, a bedside table, or the back of the bedroom door.⁴ Tucking it in a filing cabinet defeats the purpose. Paramedics have seconds, not minutes, to decide whether to start resuscitation.

When you move between care settings, the original green form travels with you. Transport teams are trained to look for it and follow it during the transfer. Facilities will scan a copy into your electronic record, but the physical form remains the primary document for EMS and transport crews.

The State Registry Backup

Washington maintains a digital Health Care Declarations Registry through the Department of Health. You can submit your signed POLST so a digital copy is accessible to providers if the paper form is unavailable, for instance if you collapse away from home. Providers who act in good faith on a registry-stored POLST are shielded from civil and criminal liability under the Natural Death Act.⁷

The registry supplements the green form; it does not replace it. Keep the original on display at home, and make sure your primary care provider, your surrogate, and any hospital you visit regularly all have copies.

Changing or Voiding the Form

You can change or revoke your POLST at any time, as long as you have the capacity to make medical decisions.⁶ If you lack capacity, your surrogate can request changes based on your known wishes or, failing that, your best interest.

To void the form, draw a line through “Physician Orders” at the top and write “VOID” in large letters across the front.³ You can also destroy it. Either action cancels the existing orders and reverts you to default full-treatment protocols. Notify your primary care provider right away so your electronic medical record, and the registry if you enrolled, can be updated.

If your preferences have shifted rather than disappeared, you need a brand new form signed by both you and a clinician. The new document replaces all previous versions. Track down and destroy every old copy: on your fridge, in your medical record, and with family members. Conflicting versions in circulation are exactly what POLST was designed to prevent, and they can lead to unwanted treatment at the worst possible moment.

Traveling Out of State

Each state sets its own rules on honoring another state’s POLST form, and there is no federal reciprocity law.⁸ Some states recognize out-of-state forms; others do not. If you spend time elsewhere, such as a winter home or regular family visits, ask a clinician in that state whether your Washington form will be followed or whether you need a local version.

If you move to Washington with a POLST from another state, the safest step is to have a Washington clinician complete a new green form. EMS crews here are trained on the specific layout and color of this state’s version.

Your Rights and Provider Protections

No hospital, insurer, or healthcare plan can require you to sign a POLST as a condition of receiving care or coverage.⁹ The form is voluntary. Anyone who pressures you to complete one, or to choose a particular treatment level, is acting outside what the law allows.

Providers who follow your POLST in good faith are protected from civil and criminal liability under the Natural Death Act.¹⁰ A provider who personally objects to withholding treatment cannot be forced to participate, but they must transfer your care to someone who will follow the orders.

1
University of Washington HDSA Center of Excellence. Physician Orders for Life Sustaining Treatment (POLST)
2
Washington State Department of Health. Portable Orders for Life Sustaining Treatment (POLST)
3
End of Life Washington. Washington State POLST Form
4
Washington State Department of Health. Washington State POLST Form
5
Washington State Legislature. RCW 7.70.065
6
Washington State Department of Health. Washington State POLST Training Curriculum for EMS Providers
7
Washington State Legislature. Washington Revised Code Chapter 70.122 – Section RCW 70.122.051
8
National POLST. POLST Legislative Guide
9
Washington State Legislature. Washington Revised Code Chapter 70.122 – Section RCW 70.122.070
10
Washington State Legislature. Washington Revised Code Chapter 70.122 – Section RCW 70.122.060