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Video 1: An Introduction to the New Jersey POLST Form

What is a POLST form?

The New Jersey POLST form is a green single page set of medical orders, written by either a doctor or nurse practitioner. These medical orders tell the medical team what to do for patients who are seriously ill or entering their final phase of life.

The POLST form is an active medical order across all medical facilities. It should travel with the patient so all health care personnel can see it. If the patient is at home, the green original should be kept in a visible place so 911 staff can find it. If the patient is in a hospital or nursing facility, it should be kept on the medical chart.

Copies of the POLST form (even if not on green paper) are valid, and we encourage all of the main doctors caring for the patient to have a copy. The patient or decision maker may also decide to share copies of the POLST form with appropriate family members or friends. These copies do not have to be printed on green paper and are valid in black and white.

In these videos, you can learn more about the POLST form and how to complete the different sections, which cover

  • Personal Goals of Care,
  • Artificial Nutrition, and
  • Resuscitation

You will also get information to help you decide whether to return to the hospital or remain in the current setting, such as in a nursing facility or at home. This is called a “Do Not Rehospitalize” order, and this order may be written onto the POLST form.

The main purpose of the POLST form is to insure that the patient receives the type of medical care that is most important to him or her during this final phase of life.

Who should have a POLST form?

The POLST form is intended for those people who may be facing serious medical problems, or entering the final years of life.

It is also recommended for all patients residing in long-term care or nursing facilities.

A POLST form may be completed by patients who are able to make their own decisions, but it may also be completed for those patients who are unable make their own decisions, such as dementia or any illness that prevents them from participating in this conversation.

The person responsible for making medical decisions for the patient may assist the doctor or nurse practitioner in completing the POLST Form.

What does a POLST form look like?

The NJ POLST form is a single-page medical order form with several sections that ask specific questions.

“POLST” stands for “Practitioner Orders for Life Sustaining Treatments”

Section A asks about personal goals of care for the patient.

The remaining sections of the form are the actual medical orders that should support the personal goals of care written in section A.

Section B asks about scope of care and type of medical treatments.

Section C asks about the use of artificial nutrition and hydration.

Section D asks about the use of CPR and artificial breathing machines.

Section E ask if other decision makers are allowed to change this form.

And Section F is a place for signatures. Both the Doctor or Nurse Practitioner and the decision maker must sign the form to make it legal.

4Step iCare Plan

An Individualized End of Life Care Plan
Our 4Step iCare Plan is a simple, 4-step approach that helps patients, families, and healthcare providers navigate through challenging medical decisions.
Learn more with our video series and helpful tools

Get Involved!

 As an agent of change. Join the Goals of Care Coalition of New Jersey to help improve end of life care for patients and families.
As a supporter of our efforts. We depend on the generosity of our donors to help the sickest and most vulnerable New Jerseyeans get the care they need and no less, and the care they want and no more. Donate today to help us provide critical information to patients and families and raise our voice with local, state and federal policy makers.

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GOCC Resources:

NJ POLST Form Videos and Documents

NJ POLST Form Videos and Documents




GOCC Resources:

NJ POLST Form Videos and Documents

NJ POLST Form Videos and Documents