Virginia POLST Form: How Portable Medical Orders Work and Who Needs One

Your advance directive doesn't travel with you in an ambulance. EMS crews responding to a 911 call at your home cannot honor a living will or written advance directive — those documents are legally binding only inside a licensed medical facility. If paramedics arrive and you're in cardiac arrest, they start full CPR unless they see a valid pre-hospital medical order. In Virginia, that means a POLST or a Durable DNR.

POLST vs. DDNR: Two Different Instruments

Virginia uses two portable medical orders, each covering different ground:

The National POLST form (Physician Orders for Life-Sustaining Treatment) is a comprehensive, multi-section medical order set designed for patients facing advanced frailty or a terminal illness with a life expectancy under 12 months. It was officially approved by the Virginia Department of Health and the Virginia POLST Collaborative in April 2023 as the preferred successor to the legacy state-specific POST (Physician Orders for Scope of Treatment) form.

The POLST covers four areas: CPR preferences (attempt or do not attempt), medical interventions level (comfort only, limited additional interventions, or full treatment), artificially administered nutrition, and discussed preferences documentation.

The Durable DNR (Do Not Resuscitate) order focuses narrowly on one decision: whether to withhold CPR, cardiac compression, endotracheal intubation, artificial ventilation, and defibrillation in the event of cardiac or respiratory arrest. It doesn't address broader treatment preferences like nutrition or level of medical intervention.

Both are physician's orders — not patient-created documents. Both must be signed by a licensed physician, nurse practitioner, or physician assistant who has a bona fide clinical relationship with the patient.

Who Needs a POLST

A POLST is not for healthy adults doing general advance planning. It's designed for people who are:

• Diagnosed with a serious illness and a life expectancy of roughly 12 months or less
• Living with advanced frailty and would not be surprised if they died within a year
• Residents of long-term care or skilled nursing facilities
• Receiving hospice or palliative care services

If you're a healthy 55-year-old creating an advance directive for the first time, you need the advance directive but probably don't need a POLST yet. When your medical situation changes, your physician will initiate the POLST conversation.

How to Get a POLST in Virginia

The POLST must be completed during a collaborative conversation between the patient (or their authorized healthcare agent) and a healthcare professional. The process works like this:

1. Your physician, NP, or PA discusses your medical condition, prognosis, and treatment goals
2. Together you complete the National POLST form — selecting preferences for each section
3. The healthcare professional signs the form
4. You or your agent sign the form
5. Both pages must be printed double-sided on a single sheet of paper

That last requirement is legally specific. If the POLST is printed on two separate sheets, EMS personnel may not recognize or honor it. Printing on bright yellow "Lift-Off Lemon" cardstock is strongly recommended for instant visual recognition, though standard white paper is legally valid.

The Irrevocability Rule for "No CPR"

One POLST provision surprises many families: if "No CPR" is selected in Section A and the patient personally signed the form, no representative, family member, or healthcare surrogate can revoke or modify that order once the patient loses decision-making capacity. The patient's documented choice is final.

If "Yes CPR" is selected instead, an authorized surrogate can later alter the orders to align with the patient's changing clinical goals. This asymmetry reflects the legal weight Virginia places on a competent patient's explicit decision to refuse resuscitation.

Coordinating POLST with Your Advance Directive

A POLST and an advance directive serve complementary functions. The advance directive names your healthcare agent and provides detailed long-term care preferences. The POLST translates the most critical preferences into immediately actionable physician's orders that EMS crews must follow.

Both documents should be uploaded to Virginia's Advance Care Planning Registry (ACPR) so they're accessible to any treating physician in the state. Keep the original yellow POLST form posted visibly at home — on the refrigerator is standard practice — where first responders can find it immediately.

The Virginia Advance Directive & Living Will Kit explains how the POLST, DDNR, and advance directive work together as a coordinated system, covers the execution requirements for each, and walks through the ACPR registration process. Get the complete toolkit to make sure your preferences are honored in every medical setting.

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