Nevada Polst - Nevada Division Of Public And Behavioral Health Page 2
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2NEVADA POLST (Physician Order for Life-Sustaining Treatment)
Patient Name:_________________________________________ DOB:__________
SIDE 2: Supplementary Patient Preferences
ORGAN DONATION
Section
I have documented on my license or state issued ID that I would like to donate my organs
D
Other Instructions
Organ
:__________________________________________________________________
Donation
Section
The following documents/persons have further information regarding patient’s/resident’s
preferences:
E
1. Advance Directive (AD): Living Will, Declaration, Durable Power of Attorney (DPOA) for Health Care
Advance
Directive
NO
YES
If no AD, skip to #2 below
AD Registered with Secretary of State:
NO
YES - Registration No:___________________
Other location: _____________________________________________
Appointed Agent #1: _______________________________ Telephone No:____________________
Appointed Agent #2: _______________________________ Telephone No:____________________
2. If no agent appointed, another person will make decisions for you as determined by Nevada law.
3. Court-Appointed Guardian
NO
YES
Name:_________________________________
Telephone No: _________________________
Section
Patient / Agent / Parent / Guardian (circle one) Approval
F
I have discussed this form, its treatment options and their implications for sustaining life with my / the
patient’s health care provider. This form reflects my treatment preferences.
Signatures
Signature: ________________________________________________________ Date: _____________
Consent for Sections A and B above were discussed with and given by:
Patient
Spouse
Adult Child
Court-Appointed Guardian
Parent of Minor
Health Care Agent (DPOA)
Other:______________________
Witnessed by (for any checked above):________________________________ Date:_______________
Preparer’s Information
Preparer’s Name (print):____________________________________________ Date:_______________
Signature of Person Preparing Form:_______________________________________________________
Section
Physician initial box to right to verify that information has been provided to the patient to
G
submit their completed and signed POLST form to the Living Will Lockbox. Authorization
forms can be found at:
Registry
For Internal Use
GENERAL INSTRUCTIONS
Record all treatments entered on this POLST as orders in patient’s chart.
Copy POLST form for patient record.
If orders change complete a new POLST and write VOID across this POLST.
If no new form is completed, full treatment and resuscitation may be provided.
Transfer or discharge patient with a current POLST form.
WHEN THIS FORM SHOULD BE REVIEWED
This form (POLST) should be reviewed periodically and if:
The patient/resident is transferred from one care setting or level to another, or
There is a substantial change in patient/resident health status, or
The patient/resident treatment preferences change.
THE LASTEST VERSION OF THE POLST FORM IS AVAILABLE FROM THE NEVADA
DIVISION OF PUBLIC AND BEHAVIORAL HEALTH.
Send original with patient when transferred or discharged
NEVADA FORM 111913
Approved December 2013
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