Severe Weather: Donate to the Arkansas Disaster Relief Program
Healthy Communities

POLST - Forms & Directions


AR POLST form is available through the Arkansas Department of Health website. Changes to the form are made through the legislative process.

Click here to download the current AR POLST form.

AR POLST (Physician Orders for Life-Sustaining Treatment) is an easily identifiable pink document that translates a patient’s goals of care and treatment preferences for end-of-life care into a physician order that transfers across AR health care settings.  The AR POLST form represents a “plan of care” for a patient with a life-limiting illness and is modeled after the Physician Order for Life-Sustaining Treatment (POLST) Paradigm which is used in many states. 

The document should be completed after a thorough discussion with the patient, and if the patient is incapacitated, by his/her legal health care representative* regarding the patient’s understanding of the illness, treatment preferences, values, and goals of care.  Completion of an AR POLST form encourages communication between doctors and patients, enables patients to make informed decisions, and clearly documents these decisions to other physicians and health care professionals.  As a result, AR POLST can help ensure that a patient’s wishes are honored, prevent unwanted or non-beneficial treatments, and reduce patient and family stress regarding decision-making.

AR POLST does not replace an advance directive for health care but can be used to operationalize the directives of the living will.

The AR POLST form is an essential part of health information records that travels with the patient as he/she moves from one health care setting to another. A copy should always be kept in the patient’s chart or medical record and be immediately accessible by other health care providers as necessary across care settings.   

An AR POLST form may be revoked/voided at any time by the patient or legal proxy.

Please click here for a detailed video describing AR POLST.
Please click here to learn about physician and nurse practitioner billing for ACP discussions.

Compliance with AR POLST

In some cases, physicians have been hesitant to follow AR POLST orders without first reassessing the person’s wishes in the current clinical situation. However, the AR POLST form states that the orders on AR POLST form should be followed until a review is completed by the accepting health care professional.  The AR POLST form should be followed even if the physician who has signed the document is not on the medical staff of the facility.

Health care institutions are encouraged to develop policies and procedures for the use of AR POLST.

The Impact of AR POLST

Research has shown that documents like AR POLST are making a difference in end-of-life care.  It serves as a useful tool for starting a dialogue with patients regarding their wishes about end-of-life care.

Studies in states that have POLST available have revealed that among patients with completed POLST documents, treatment preferences were respected 98% of the time, and no one received unwanted CPR, intubation, intensive care, or feeding tubes. As a result, POLST has helped to bridge the gap between preferred treatment options and the actual treatments patients receive.

Public Health Accrediation Board
Arkansas Department of Health
© 2017 Arkansas Department of Health. All Rights Reserved.
4815 W. Markham, Little Rock, AR 72205-3867