Physician Orders For Life- Sustaining Treatment (Polst)
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2PHYSICIAN ORDERS FOR LIFE- SUSTAINING TREATMENT (POLST)
This is a Physician Order guided by the patient’s medical condition and based upon personal preferences
verbalized to the Physician or expressed in an Advance Directive.
Patient’s Name _____________________________ ____________________________ ____________________________________
(First)
(Middle)
(Last)
Last four digits of SSN:____________________ Date of Birth _____________
Gender: Male
Female
.
A
CARDIOPULMONARY RESUSCITATION (CPR): Patient has no pulse and is not breathing
CODE
Attempt Resuscitation (CPR).
STATUS
Allow Natural Death (AND) - Do Not Attempt Resuscitation.
Resuscitation Orders are to remain in effect during any surgical or invasive procedure.
Check all
When not in cardiopulmonary arrest, follow orders in B, C and D.
that apply
.
MEDICAL INTERVENTIONS: Patient has pulse and /or is breathing
Comfort Measures: Use medication by any route, positioning, wound care, and other measures to relieve pain and
suffering. Use oxygen, suction, and manual treatment of airway obstruction as needed for comfort. Do not transfer to
B
hospital for life-sustaining treatment.
Check
Limited Additional Interventions: Includes Comfort Measures and medical treatment, IV fluids, and cardiac
One
monitor as indicated. Does not include intubation or mechanical ventilation. Avoid intensive care. Transfer to hospital if
indicated.
Additional Treatment: Includes Limited Additional Interventions, lab tests, blood products. Transfer to hospital if
indicated.
Full Treatment: Includes Additional Treatment and intubation, mechanical ventilation, and cardioversion as
indicated. Includes intensive care. Transfer to hospital if indicated.
Additional Orders (e.g. dialysis):
ANTIBIOTICS
No antibiotics: Use other measures to relieve symptoms.
C
Determine use or limitation of antibiotics when infection occurs.
Check
Use antibiotics if life can be prolonged.
One
Additional Orders:
ARTIFICIALLY ADMIINISTERED NUTRITION/FLUIDS
D
Where indicated, always offer food or fluids by mouth if feasible
Check
No artificial nutrition by tube.
No IV fluids.
One
Defined trial period of artificial nutrition by tube.
Defined trial period of IV fluids.
In Each
Long-term artificial nutrition by tube.
Long-term IV fluids.
Additional Orders:
Column
REASON FOR ORDERS AND SIGNATURES
To the best of my knowledge these orders are consistent with the patient’s current medical condition and preferences as
E
indicated by:
Check
My discussion with the Patient
My discussion with the Patient’s Authorized Representative
All That
My review of the Patient’s Advance Directive
Verbal consent was given for an “allow natural death” order
Apply
Physician’s Printed Name
Physician’s Signature
Date
Phone
License No.
State
Patient’s Printed Name
Patient’s Signature
Date
Phone
Patient Authorized Representative’s Printed Name
Representative’s Signature
Date
Phone
(if patient lacks decision making capacity )
(if patient lacks decision making capacity)
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