POLST, DNR Forms and Advance Directives in California Assisted Living

These three documents do different jobs. The National Institute on Aging describes advance directives as legal documents that provide instructions for medical care and only go into effect if you cannot communicate your own wishes. The Coalition for Compassionate Care of California, which publishes the California POLST website, describes POLST as a medical order for people with serious illness, signed by the patient or decision maker and by a physician, nurse practitioner or physician assistant.

The POLST program says a POLST does not replace an advance directive. A person still needs a directive to appoint a health care agent. If the two conflict, it says the more recent document should be followed. Filling out a POLST is entirely voluntary.

Assisted living communities and board and care homes are licensed in California as residential care facilities for the elderly (RCFEs). Health and Safety Code section 1569.156 puts four duties on every RCFE:

• Not to condition the provision of care, or otherwise discriminate, based on whether a person has executed an advance directive.
• To provide education to staff on issues concerning advance directives.
• To provide written information, upon admission, about the right to make decisions concerning medical care, including the right to accept or refuse treatment and the right to formulate advance directives.
• To provide written information about the home's policies on carrying out those rights.

Title 22 section 87469 adds detail. On admission, the home must give each resident and the resident's representative or responsible person the state brochure "Your Right To Make Decisions About Medical Treatment" and a copy of the regulation's emergency rules. It also says residents shall be permitted to have a request to forgo resuscitative measures, an advance health care directive and a do-not-resuscitate form in their facility file. California law counts both the prehospital DNR form and the POLST as a request regarding resuscitative measures.

Other admission paperwork is in our guide to move-in requirements. Whether a person still has the capacity to sign these documents is a question for the doctor or an elder law attorney. Our guide to when a parent refuses assisted living explains capacity in general terms.

Title 22 section 87465 requires a home to telephone 911 immediately when there is an imminent threat to a resident's health, including an apparent life-threatening medical crisis. For a resident who has an advance directive or a request regarding resuscitative measures on file, section 87469 says staff shall do one of the following:

1. 1

   Call 911 and present the form

   Immediately telephone 911, present the directive or form to the responding emergency medical personnel, and identify the resident as the person the order refers to.

2. 2

   Or hand it to a physician or nurse who is there

   Immediately give the form to a physician, registered nurse or licensed vocational nurse, if one is in the resident's presence at the time of the emergency and assumes responsibility.

3. 3

   Or, for a hospice resident, call the hospice

   For a terminally ill resident on hospice who has completed a directive or form under Health and Safety Code section 1569.73, when the emergency shows symptoms of impending death directly related to the expected course of the terminal illness, the home may immediately notify the hospice agency in lieu of calling 911. For any other emergency, staff must call 911.

4. 4

   Or follow the home's own policy, if it employs health care providers

   A home that employs health care providers may set a written policy under section 1569.74. Under such a policy, only a licensed health care provider employed by the home and on the premises at the time may act to honor the request.

Afterward, staff must notify the resident's hospice agency and health care surrogate decision maker, if there are any.

Notice what is missing. The regulation does not tell caregivers to read a POLST and decide for themselves what to withhold. It tells them to get the form to the people who can act on it. Health and Safety Code section 1569.74 says the request may be honored by an emergency medical technician or by a health care provider who responds to emergencies, and that a home without its own policy may present the form to the paramedics when the resident or surrogate has authorized that in writing. Ask each home what its staff do in the minutes before paramedics arrive.

A June 2025 notice from the Community Care Licensing Division adds that even when 911 is called, residents keep the right to accept or refuse medical treatment and transport to a hospital.

The POLST program says the original form belongs to the patient, and that in a hospital, nursing home or other facility the form is kept in the medical record or file until discharge. It also says a POLST is valid on any color of paper and that faxes and photocopies are as valid as the original, although the bright pink paper makes it easier to find in an emergency.

Ask the home where the form is kept, whether night staff can reach it, and whether a copy goes with the resident to the hospital.

Wishes change. The POLST program says a POLST can be changed or voided at any time, and that it is a good idea to review it when overall health changes or the person moves from one care setting to another. It says it is better to void the old form and complete a new one. Give the home the new form right away. Section 1569.74 also bars facility staff, in a home with a resuscitation policy, from signing a directive document as a witness or acting as the resident's surrogate decision maker.

The hospice exception in step three applies only in a home that holds a hospice waiver, and only when the home has documented that its staff were trained by the hospice on the expected course of the illness and the symptoms of impending death. Without those pieces, staff must call 911 even for a resident who is dying as expected. The waiver itself is covered in hospice in assisted living in California, and the wider planning in end-of-life care in assisted living.

Hamssa Benrekia is a senior living placement specialist in Torrance whose background is in hospice, palliative care and home health. She helps families in the South Bay and Harbor area of Los Angeles County find licensed assisted living, board and care homes and memory care, including homes that can care for a person on hospice. She can help you ask a home how it handles these forms. She does not give medical or legal advice, and the forms themselves are completed with the doctor. More topics are in the California Assisted Living Placement Guide. To talk about a search, contact Hamssa.