Your POLST Form

This tool will help you complete your Physician Orders for Life-Sustaining Treatment (POLST) form. This is the same form used by hospitals across Georgia.

This should take about 10–15 minutes. Your answers are automatically saved on this device as you go.

Step 1 — About You

Let’s start with some basic information. This will appear on your completed POLST form.

We will send your completed form to this email address

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This medical scenario was illustrated using AI-generated video

If your heart stopped beating, would you want doctors to try CPR?

Your answer has been saved. You can change it anytime before printing.

Mechanical Ventilation (Breathing Machine)

Before answering the next question, please watch the video below to understand what being on a ventilator really looks like.

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If you stopped breathing on your own, would you want a breathing tube placed and a machine to breathe for you?

Your answer has been saved. You can change it anytime before printing.

When Your Heart IS Beating — How Aggressive Should Your Care Be?

The previous question was about what happens if your heart stops beating. This next question is different — it is about what you want if your heart IS still beating but you are getting worse.

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If your heart is still beating but you are getting worse, what level of care do you want?

Your answer has been saved. You can change it anytime before printing.

Feeding Tubes

Before answering the next question, please watch the video below to understand what a feeding tube really means for seriously ill patients.

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For feeding tube nutrition, choose one:

Your answer has been saved. You can change it anytime before printing.

For IV fluids, choose one:

Your answer has been saved. You can change it anytime before printing.

Antibiotics

If you develop a serious infection while you are seriously ill, your doctor will need to know how you want it treated.

  • Antibiotics can sometimes treat infections and make you feel more comfortable — for example treating a bladder infection that is causing pain
  • However in patients with serious illness, antibiotics often extend dying rather than restore health
  • Antibiotics can have side effects including nausea, diarrhea, allergic reactions, and in some cases kidney damage

If you develop a serious infection, how do you want it treated?

Your answer has been saved. You can change it anytime before printing.

Almost Done!

You have completed your POLST form. Here is what to do next.

1
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Review Your Answers

Scroll back up and review all of your answers to make sure everything is correct.

2
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Generate Your Form

Click the button below to generate your completed POLST form. We will send it to your email address so you have a copy.

3
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Sign With Your Doctor

Print the form and sign it in front of your doctor. Your doctor will co-sign as the attending physician. The form is not valid until your doctor signs it.

4
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Share Your POLST

Give a copy to your Healthcare Agent, your family, and ask your doctor to put it in your medical record. Keep one copy at home where it can be easily found.

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Full Advance Directive Resources Coming Soon

We're building a comprehensive, easy-to-use guide to help you and your loved ones create advance directives that reflect your values and wishes. This section will include Georgia-specific forms, step-by-step guidance, and answers to common questions.

What is an Advance Directive?

  • A legal document that records your healthcare wishes if you become unable to speak for yourself
  • Includes a Living Will (treatment preferences) and Healthcare Power of Attorney (who decides for you)
  • Georgia also recognizes the POLST form (Physician Orders for Life-Sustaining Treatment) for those with serious illness
  • Can be changed or revoked at any time as long as you have the capacity to do so
  • Relieves family members from having to guess what you would want
  • Does not require an attorney — but our team can help guide the conversation
Why it matters

A gift to the people you love

Advance directives aren't about giving up — they're about being heard.

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Protect your wishes

Without a directive, medical decisions may be made without knowing what you would have wanted — even by people who love you deeply.

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Ease family burden

Families often face impossible decisions in moments of crisis. Your advance directive gives them permission to honor your wishes rather than second-guess.

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Start the conversation

Talking about your wishes isn't morbid — it's loving. Our team can help facilitate these conversations in a safe, supportive environment.