HIPAA PERMITS DISCLOSURE OF POLST TO HEALTH CARE PROFESSIONALS AS NECESSARY FOR TREATMENT
IDPH UNIFORM PRACTITIONER ORDER FOR
LIFE-SUSTAINING TREATMENT (POLST) FORM
State of Illinois
Illinois Department of Public Health
Patient Last Name
Patient First Name
For patients, use of this form is completely voluntary.
Follow these orders until changed. These medical orders are
based on the patient’s medical condition and preferences.
Date of Birth (mm/dd/yy)
Any section not completed does not invalidate the form and
implies initiating all treatment for that section. With significant
change of condition new orders may need to be written.
If patient has no pulse and is not breathing.
Do Not Attempt Resuscitation/DNR
(Selecting CPR means Full Treatment in Section B is selected)
When not in cardiopulmonary arrest, follow orders B and C.
If patient is found with a pulse and/or is breathing.
Full Treatment: Primary goal of sustaining life by medically indicated means. In addition to treatment de-
scribed in Selective Treatment and Comfort-Focused Treatment, use intubation, mechanical ventilation and
cardioversion as indicated. Transfer to hospital and/or intensive care unit if indicated.
Selective Treatment: Primary goal of treating medical conditions with selected medical measures.
In addition to treatment described in Comfort-Focused Treatment, use medical treatment, IV fluids and IV
medications (may include antibiotics and vasopressors), as medically appropriate and consistent with patient
preference. Do Not Intubate. May consider less invasive airway support (e.g. CPAP, BiPAP). Transfer to hos-
pital, if indicated. Generally avoid the intensive care unit.
Comfort-Focused Treatment: Primary goal of maximizing comfort. Relieve pain and suffering through the
use of medication by any route as needed; use oxygen, suctioning and manual treatment of airway obstruction.
Do not use treatments listed in Full and Selective Treatment unless consistent with comfort goal. Request
transfer to hospital only if comfort needs cannot be met in current location.
Optional Additional Orders
MEDICALLY ADMINISTERED NUTRITION
(if medically indicated) Offer food by mouth, if feasible and as desired.
q Long-term medically administered nutrition, including feeding tubes.
Additional Instructions (e.g., length of trial period)
q Trial period of medically administered nutrition, including feeding tubes. __________________________________________
q No medically administered means of nutrition, including feeding tubes. __________________________________________
DOCUMENTATION OF DISCUSSION
(Check all appropriate boxes below)
Agent under health care power of attorney
Parent of minor
Health care surrogate decision maker (See Page 2 for priority list)
Signature of Patient or Legal Representative
Signature of Witness to Consent
(Witness required for a valid form)
I am 18 years of age or older and acknowledge the above person has had an opportunity to read this form and have witnessed the
giving of consent by the above person or the above person has acknowledged his/her signature or mark on this form in my presence.
Signature of Authorized Practitioner
(physician, licensed resident (second year or higher), advanced practice nurse or physician assistant)
My signature below indicates to the best of my knowledge and belief that these orders are consistent with the patient’s medical condition and preferences.
Print Authorized Practitioner Name (required)
) _________ - ______________
Authorized Practitioner Signature (required)
(Prior form versions are also valid.)
Form Revision Date - April 2016
SEND A COPY OF FORM WITH PATIENT WHENEVER TRANSFERRED OR DISCHARGED • COPY ON ANY COLOR OF PAPER IS ACCEPTABLE • 2016