Physician Orders for Life-Sustaining Treatment (POLST)


(Forms shown above are examples of how the POLST form should look in Maine)

Honoring patient preferences is a crucial element in providing quality end-of-life care.  To help physicians and other health care providers (i.e. Physician Assistants, Nurse Practitioners) discuss and convey a patient’s wishes regarding resuscitation (CPR), and other life-sustaining treatment, the Maine POLST Coalition came together to bring the program to the State of Maine.  This form can be used statewide by health care professionals and facilities.  Please note that the POLST form does not replace a Maine Advance Directive.

POLST is intended for patients with serious health conditions who:

  • Want to avoid or receive any or all life-sustaining treatment;
  • Want all attempts at sustaining life documented;
  • Reside in a long-term care facility or require long-term care services; and/or
  • Might die within the next year.

Completion of the POLST form begins with a conversation, or a series of conversations between the patient, the patient’s health care authorized representative*, and a qualified, trained health care professional that defines the patient’s goals for care, reviews possible treatment options on the entire POLST form, and ensures shared, informed medical decision-making.  Although the conversation(s) about goals and treatment options may be initiated by any qualified and trained health care professional (i.e. nurse, social worker, PA, NP, etc), a licensed physician must always, at a minimum:

  • Confer with the patient and/or patient’s authorized representative about the patient’s diagnosis, prognosis, goals for care, treatment preferences, and consent by the appropriate decision maker, and
  • Sign the orders derived from that discussion.

It is important to point out as well, that the health care professional completing the form, needs to sign the back of the form (under Section F) and fill in their contact information as well.  Even if the physician signing the front of the form is the person responsible for having the goals of care conversation, they need to fill in the box labeled “Health Care Professional Preparing Form”.  For ways to bring up the conversation with your patient, please click here.


*Authorized Representative includes, in order of priority, a health care agent (same as durable health care power of attorney or agent named in advance directive), court appointed guardian, parent of minor, or surrogate as defined in 18-A MRS § 5-801.