Illinois' uniform portable order for patients at risk of a life-threatening event because of a serious life-limiting condition, which may include advanced frailty. It records CPR, scope of treatment and medically administered nutrition decisions, and hospitals, nursing homes and EMS must honor it. A practitioner completes it after a conversation with the patient or representative, and it also serves as the state's out-of-hospital DNR.
A physician, licensed resident in the second year or higher, advanced practice nurse or physician assistant completes the orders and signs Section F; the practitioner may be licensed in Illinois or in the state where the patient is treated. The patient or legal representative (parent of a minor, health care agent or surrogate) signs Section E.
Enter the patient's last name, first name, middle initial, date of birth (mm/dd/yyyy) and address. The header reminds patients that the form is completely voluntary and tells providers to complete it only after a conversation with the patient or representative. Treatment or admission cannot be conditioned on having a POLST.
Required: select one. YES CPR means attempt resuscitation using all indicated modalities per standard protocol and requires choosing Full Treatment in Section B. NO CPR means Do Not Attempt Resuscitation (DNAR). This section applies only when the patient has no pulse.
Applies when the patient has a pulse. Choose Full Treatment (intubation, mechanical ventilation, cardioversion as indicated), Selective Treatment (no intubation or invasive ventilation; CPAP, BiPAP, IV fluids, antibiotics, vasopressors and antiarrhythmics allowed; transfer if indicated) or Comfort-Focused Treatment (symptom management, transfer only if comfort cannot be achieved). This section may be left blank; then Full Treatment is followed.
Optional free text for orders in addition to A and B, such as withholding blood products or no dialysis. IDPH guidance notes this space can also record the patient's wishes about how the POLST applies during surgery or unforeseen events. The form warns that EMS protocols may limit what emergency responders can do with orders written here.
Food by mouth is offered if tolerated. Choose artificial nutrition and hydration by any means, including surgically placed tubes; a trial period with no surgically placed tubes; or no artificial nutrition or hydration. The section may be left blank, in which case standard of care is provided.
Required. The signer prints their name, signs and dates, and checks their relationship: patient, parent of minor, agent under power of attorney for health care, or health care surrogate decision maker. A surrogate follows the Health Care Surrogate Act priority list on page 2. eSigned documents are valid.
Required. A physician, licensed resident (second year or higher), advanced practice nurse or physician assistant prints their name, signs and dates, attesting the orders are consistent with the patient's condition and preferences. A phone number is requested. eSignatures are valid.
Record which advance directives were available (power of attorney for health care, living will, declaration for mental health treatment or none) and the preparer's name, title, phone and date. The page also lists when to review the form, such as care transfers, health changes or new implantable devices, and how to void it.
Download the current version from the source each time; forms change without notice.
IDPH Uniform Practitioner Order for Life-Sustaining Treatment (POLST) Form
Formulario de Órdenes del Médico para el Tratamiento de Soporte Vital (POLST) del IDPH
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Sources for this guide
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Two signatures are required. The patient, or a legal representative such as a parent of a minor, agent under a health care power of attorney or health care surrogate, signs Section E. A qualified practitioner signs Section F: a physician, licensed resident in the second year or higher, advanced practice nurse or physician assistant, licensed in Illinois or the state where the patient is treated.
No. IDPH guidance states that a witness signature to consent is no longer required by Illinois law. Verbal or phone consent from the patient or legal representative is acceptable when documented under facility or community policy, and the form is valid once both the patient or representative and the qualified practitioner have signed.
Yes. Use of the original is encouraged, but digital copies, photocopies and faxes on any color paper are legal and valid, and forms with eSignatures are valid too. Individual facilities may have their own policies on accepting orders written on forms other than the IDPH form, so check local policy when a patient arrives with a different document.
Yes. IDPH posts the form in Spanish along with Arabic, Simplified Chinese, Traditional Chinese, French, Hindi, Korean and Polish versions. The English form is the September 2022 revision, and the translations are dated May 2023. The section structure and signature requirements are the same in every language.