PHYSICIAN 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 _____________________________ ____________________________ ____________________________________
Last four digits of SSN:____________________ Date of Birth _____________
CARDIOPULMONARY RESUSCITATION (CPR): Patient has no pulse and is not breathing
Attempt Resuscitation (CPR).
Allow Natural Death (AND) - Do Not Attempt Resuscitation.
Resuscitation Orders are to remain in effect during any surgical or invasive procedure.
When not in cardiopulmonary arrest, follow orders in B, C and D.
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
hospital for life-sustaining treatment.
Limited Additional Interventions: Includes Comfort Measures and medical treatment, IV fluids, and cardiac
monitor as indicated. Does not include intubation or mechanical ventilation. Avoid intensive care. Transfer to hospital if
Additional Treatment: Includes Limited Additional Interventions, lab tests, blood products. Transfer to hospital if
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):
No antibiotics: Use other measures to relieve symptoms.
Determine use or limitation of antibiotics when infection occurs.
Use antibiotics if life can be prolonged.
ARTIFICIALLY ADMIINISTERED NUTRITION/FLUIDS
Where indicated, always offer food or fluids by mouth if feasible
No artificial nutrition by tube.
No IV fluids.
Defined trial period of artificial nutrition by tube.
Defined trial period of IV fluids.
Long-term artificial nutrition by tube.
Long-term IV fluids.
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
My discussion with the Patient
My discussion with the Patient’s Authorized Representative
My review of the Patient’s Advance Directive
Verbal consent was given for an “allow natural death” order
Physician’s Printed Name
Patient’s Printed Name
Patient Authorized Representative’s Printed Name
(if patient lacks decision making capacity )
(if patient lacks decision making capacity)