Physician Orders For Life-Sustaining Treatment
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1
2FORM SHALL ACCOMPANY PERSON WHEN TRANSFERRED OR DISCHARGED
Oklahoma Physician Orders for Life-Sustaining Treatment
Patient’s Last Name/First Name/Middle Initial
(POLST)
Date of Birth:
This Physician Order set is based on the patient's current medical condition and wishes and is to be
reviewed for potential replacement in the case of a substantial change in either, as well as in other
Effective Date of this Form:
cases listed under F. Any section not completed indicates full treatment for that section. Photocopy
Form must be reviewed at least annually.
or fax copy of this form is legal and valid.
A.
C
R
(CPR): Person has no pulse and is not breathing.
ARDIOPULMONARY
ESUSCITATION
Check
Attempt Resuscitation (CPR)
Do Not Attempt Resuscitation (DNR/ no CPR)
One
When not in cardiopulmonary arrest, follow orders in B, C, and D below.
M
I
: Person has pulse and/or is breathing.
EDICAL
NTERVENTIONS
Full Treatment Includes the use of intubation, advanced airway interventions, mechanical ventilation, defibrillation or
cardio version as indicated, medical treatment, intravenous fluids, and cardiac monitor as indicated. Transfer to hospital if
indicated. Include intensive care. Includes treatment listed under “Limited Interventions” and “Comfort Measures.”
Treatment Goal: Attempt to preserve life by all medically effective means.
Limited Interventions Includes the use of medical treatment, oral and intravenous medications, intravenous fluids, cardiac
B.
monitoring as indicated, noninvasive bi-level positive airway pressure, a bag valve mask, or other advanced airway interventions.
Check
Includes treatment listed under “Comfort Measures.” Do not use intubation or mechanical ventilation. Transfer to hospital if
indicated. Avoid intensive care. Treatment Goal: Attempt to preserve life by basic medical treatments.
One
Comfort Measures only Includes keeping the patient clean, warm, and dry; use of 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. Transfer from current location to intermediate facility only if needed and adequate to meet comfort
needs and to hospital only if comfort needs cannot otherwise be met in the patient’s current location (e.g., hip fracture; if
intravenous route of comfort measures is required).
____________________________________________________________________________
Additional Orders:
A
NTIBIOTICS
C.
Use Antibiotics to preserve life.
Check
Trial period of antibiotics if and when infection occurs. *Include goals below in E.
One
Initially, use antibiotics only to relieve pain and discomfort. +Contact patient or patient’s representative for further direction.
Additional Orders: ___________________________________________________________________________________
A
N
H
SSISTED
UTRITION AND
YDRATION
Administer oral fluids and nutrition, if necessary by spoon feeding, if physically possible.
TPN (Total Parenteral Nutrition-
Tube Feeding
Intravenous (IV) Fluids for Hydration
D.
provision of nutrition into blood vessels)
Check
TPN long-term if needed
Long-term feeding tube if needed
Long-term IV fluids if needed
One in
Each
TPN for a trial period*
Feeding tube for a trial period*
IV fluids for a trial period*
Column
Initially, no TPN+
Initially, no tube feeding
Initially, no IV fluids
+
Additional Orders:_____________________________________________________________________________
*Include goals below in E. +Contact patient or patient’s representative for further direction.
P
P
B
POLST F
ATIENT
REFERENCES AS A
ASIS FOR THIS
ORM
Patient Goals/Medical Condition:
The patient has an advance directive for health care in accordance with Sections 3101.4 or 3101.14 of Title 63 of the Oklahoma Statutes.
The patient has a durable power of attorney for health care decisions in accordance with paragraph 1 of Subsection B of Section 1072.1 of
Title 58 of the Oklahoma Statutes.
Date of execution: ______________
If POLST not being executed by patient: We certify that this POLST is in accordance with the patient’s advance directive.
E.
_______________________________ ________________________________ ______________________________
Check
Name and Position (print)
Signature
Signature of Physician
all that
Directions given by:
apply
Patient
Minor’s custodial parent or guardian
Attorney-in-fact
Health care proxy
Other legally authorized person : ____________________________ Basis of Authority_________________________
Printed Name
Signature
Date
Attending Physician
Patient or other individual checked
above (patient’s representative)
Health care professional preparing
form (besides doctor)
HIPAA PERMITS DISCLOSURE TO HEALTH CARE PROFESSIONALS AND PROXY DECISION MAKERS AS NECESSARY FOR TREATMENT
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