Polst: Provider Orders For Life Sustaining Treatment (Page 2 of 2) in pdf

POLST

summary of goals

disCussed witH:

Check

(check all that apply)

All That

tHe basis for tHese orders is patient’s

patient

Apply

best interest

request

parent(s) of minor

Known preferenCe

otHer:

HealtH Care agent:

HealtH Care direCtive/

Court-appointed guardian

living will

none

otHer:

Name of Health Care Professional Preparing Form

Preparer Title

Phone Number

Date Prepared

signature of patient or HealtH Care agent / guardian / surrogate

tHese orders refleCt tHe patient’s treatment wisHes

Name

Date

Relationship to Patient

Phone Number

Signature*

direCtions for HealtH Care professionals

• A patient with capacity or the surrogate (if patient lacks capac-

Completing polst

• Must be completed by a health care professional based on patient

ity) can revoke the POLST at any time and request alternative

preferences and medical indications.

treatment.

• If the goal is to support quality of life in last phases of life,

• Comfort care only: At this level, provide only palliative measures

then DNR must be selected in Section A.

to enhance comfort, minimize pain, relieve distress, avoid invasive

• If the goal is to maintain function and quality of life, then

and perhaps futile medical procedures, all while preserving the

either CPR or DNR may be selected in Section A.

patients’ dignity and wishes during their last moments of life.

• If the goal is to live as long as possible, then CPR must be

This patient must be designated DNAR status in section A for

designated in Section A.

this choice to be applicable in section B.

• POLST must be signed by a physician, nurse practitioner, Doctor

• Limit Interventions and Treat Reversible Conditions: The goal

of Osteopathy, or Physician Assistant (when delegated). * The

at this level is to provide limited additional interventions aimed at

signature of the patient or heath care agent / guardian/ surrogate

the treatment of new and reversible illness or injury or manage-

is strongly encouraged.

ment of non life-threatening chronic conditions. Treatments may

be tried and discontinued if not effective.

using polst

• Provide Life-Sustaining Care: The goal at this level is to pre-

• Any section of POLST not completed implies most aggressive

serve life by providing all available medical care and advanced life

treatment for that section.

support measures when reasonable and indicated. For patient’s

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

designated DNR status in section A above, medical care should

a patient who has chosen “Do Not Attempt Resuscitation.”

be discontinued at the point of cardio and respiratory arrest.

• Oral fluids and nutrition must always be offered if medically

feasible.

reviewing polst

This POLST should be reviewed periodically and a new POLST

• When comfort cannot be achieved in the current setting, the pa-

completed if necessary when:

tient, including someone with “Comfort Measures Only,” should

1. The patient is transferred from one care setting or level

be transferred to a setting able to provide comfort.

to another, or

• An IV medication to enhance comfort may be appropriate for a

2. There is a substantial change in the patient’s health

patient who has chosen “Comfort Measures Only”.

status.

• Artificially-administered hydration is a measure which may pro-

3. A new POLST should be completed when the patient’s treat-

long life or create complications. Careful consideration should be

ment preferences change.

made when considering this treatment option.

Minnesota POLST — October, 2011

POLST

faxed Copies and pHotoCopies of tHis form are valid.

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

Polst: Provider Orders For Life Sustaining Treatment Page 2

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