PA – Orders for Life-Sustaining Treatment (POLST)
from the PA Department of Health
This form was developed by the Pa Department of Health’s Patient Life Sustaining Wishes Committee and was designed to be consistent with Pennsylvania law. This form was developed by the Pa Department of Health’s Patient Life Sustaining Wishes Committee and was designed to be consistent with Pennsylvania law. There are significant advantages to using a form that contains standardized language and is produced in a distinctive and easily recognizable format.
In order to maintain continuity throughout Pennsylvania, please follow these printing instructions:
*** Print POLST Form on 110# Pulsar Pink Card Stock ***
Click on the links below to download
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