Physician Orders For Life-Sustaining Treatment (Page 2 of 2) in pdf

NFORMATION FOR

ATIENT OR

EPRESENTATIVE OF

ATIENT

AMED ON THIS

ORM

The POLST form is always voluntary and is usually for persons with advanced illness. Before providing information for or

signing it, carefully read “Information for Patients and Their Families – Your Medical Treatment Rights Under Oklahoma

Law,” which the health care provider must give you. It is especially important to read the sections on CPR and food and fluids,

which have summaries of Oklahoma laws that may control the directions you may give. POLST records your wishes for

medical treatment in your current state of health. Once initial medical treatment is begun and the risks and benefits of further

therapy are clear, your treatment wishes may change. Your medical care and this form can be changed to reflect your new

wishes at any time. However, no form can address all the medical treatment decisions that may need to be made. An advance

health care directive is recommended, regardless of your health status. An advance directive allows you to document in detail

your future health care instructions and/or name a health-care agent to speak for you if you are unable to speak for yourself.

The State of Oklahoma affirms that the lives of all are of equal dignity regardless of age or disability and emphasizes that no

one should ever feel pressured to agree to forego life-preserving medical treatment because of age, disability or fear of being

regarded as a burden.

If this form is for a minor for whom you are authorized to make health care decisions, you may not direct denial of medical

treatment in a manner that would violate the child abuse and neglect laws of Oklahoma. In particular, you may not direct the

withholding of medically indicated treatment from a disabled infant with life-threatening conditions, as those terms are defined

in 42 U.S.C., Section 5106g or regulations implementing it and 42 U.S.C., Section 5106a.

IRECTIONS FOR

OMPLETING AND

MPLEMENTING

ORM

POLST - The signature of the patient or the patient’s representative is required.

COMPLETING

POLST must be reviewed and prepared in consultation with the patient or the patient's representative after that person has

been given a copy of “Information for Patients and Their Families – Your Medical Treatment Rights Under Oklahoma Law .”

POLST must be reviewed and signed by a physician to be valid. Be sure to document the basis for concluding the patient had

or lacked capacity at the time of execution of the form in the patient's medical record. If the patient lacks capacity, any current

advance directive form must be reviewed and the patient’s representative and physician must both certify that POLST complies

with it. The signature of the patient or the patient's representative is required; however, if the patient's representative is not

reasonably available to sign the original form, a copy of the completed form with the signature of the patient's representative

must be placed in the medical record as soon as practicable and "on file" must be written on the appropriate signature line on

this form.

IMPLEMENTING POLST

If a minor protests a directive to deny the minor life-saving treatment, the denial of treatment may not be implemented pending

issuance of a judicial order resolving the conflict. A health care provider unwilling to comply with POLST must comply with

the transfer and treatment pending transfer requirements of Section 3101.9 of Title 63 of the Oklahoma Statutes as well as

those of the Nondiscrimination in Treatment Act, Sections 3090.2 and 3090.3 of Title 63 of the Oklahoma Statutes.

REVIEWING POLST

This POLST must be reviewed at least annually or earlier if:

•

The patient is admitted to or discharged from a medical care facility;

•

There is a substantial change in the patient's health status; or

•

The treatment preferences of the patient or patient’s representative change

The same requirements for participation of the patient or patient’s representative, and signature by both a physician and the

patient or the patient’s representative, that are described under “COMPLETING POLST” also apply when POLST is

reviewed, and must be documented in Section I.

REVOCATION OF POLST

If POLST is revised or becomes invalid, write in bold the word “VOID” in large letters on the front of the form. After voiding

the form a new form may be completed. A patient with capacity or the individual or individuals authorized to sign on behalf of

the patient in Section E of this form may void this form. If no new form is completed, full treatment and resuscitation is to be

provided, except as otherwise provided by Oklahoma law.

: Periodic review confirms current form or may require completion of new form

EVIEW

ECTION

Date of

Location of

Patient or Representative

Physician Signature

Outcome of Review

Review

Signature

 FORM CONFIRMED – No Change

 FORM VOIDED, see updated form

 FORM VOIDED, no new form

 FORM CONFIRMED – No Change

 FORM VOIDED, see updated form

 FORM VOIDED, no new form

 FORM CONFIRMED – No Change

 FORM VOIDED, see updated form

 FORM VOIDED, no new form

ONTACT

NFORMATION

Patient/Representative

Relationship

Phone number

Email address

Health Care Professional Preparing Form

Relationship

Phone number

Email address

OAG Form 09-01-2016

Physician Orders For Life-Sustaining Treatment Page 2

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