Polst: Provider Orders For Life Sustaining Treatment printable pdf download

POLST:

Provider Orders for Life Sustaining Treatment

POLST

Hipaa permits disClosure of polst to otHer HealtH Care providers as neCessary

provider orders for

life-sustaining treatment (polst)

Last Name

FIRST follow these orders, THEN contact the patient’s provider. This

First/Middle Initial

is a provider order sheet based on the patient’s medical condition and

wishes. POLST translates an advance directive into provider orders.

Date of Birth

Any section not completed implies the most aggressive treatment

for that section. Patients should always be treated with dignity and

respect.

Primary Care Provider/Phone

Cardiopulmonary resusCitation (Cpr):

Patient has no pulse and is not breathing.

Check

dnr/do not attempt resusCitation (Allow Natural Death)

One

Cpr/attempt resusCitation

An automatic external defibrillator (AED) should not be used for a

When not in cardiopulmonary arrest, follow orders in B and C.

patient who has chosen “Do Not Attempt Resuscitation.”

goals of treatment:

Patient has pulse and/or is breathing. See Section A regarding CPR if pulse is lost.

Additional Orders (e.g. dialysis, etc.)

Check

— Do not intubate but use medication, oxygen, oral suction, and manual

Comfort Care

One

clearing of airways, etc. as needed for immediate comfort.

Goal

Check all that apply:

 Avoid calling 911, call ______________________________ instead

 If possible, do not transport to ER (when patient can be made comfortable at residence)

 If possible, do not admit to the hospital from the ER (e.g. when patient can be made com-

fortable at residence)

— Provide interventions aimed at treatment of new or reversible ill-

limit interventions and treat reversible Conditions

ness / injury or non-life threatening chronic conditions. Duration of invasive or uncomfortable interventions should generally

be limited. (Transport to ER presumed)

Check one:

 Do not intubate

 Trial of intubation (e.g.______days) or other instructions: _______________________________________________________

 Intubate long-term if necessary

provide life sustaining treatment

Intubate, cardiovert, and provide medically necessary care to sustain life. (Transport to ER presumed)

interventions and treatment

(check one)

antibiotiCs

Check

 No Antibiotics (Use other methods to relieve symptoms whenever possible.)

All That

 Oral Antibiotics Only (No IV/IM)

Apply

 Use IV/IM Antibiotic Treatment

Additional Orders:

(check all that apply)

nutrition/Hydration

 Offer food and liquids by mouth (Oral fluids and nutrition must always be



offered if medically feasible)

 Tube feeding through mouth or nose

 Tube feeding directly into GI tract

 IV fluid administration

 Other:

Provider Name (MD/DO/NP/PA when delegated, are acceptable)

Provider Signature

Date

faxed Copies and pHotoCopies of tHis form are valid.

POLST

to void tHis form, draw a line aCross seCtions a - d and write “void” in large letters.

Polst: Provider Orders For Life Sustaining Treatment

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