Physician Orders For Life-Sustaining Treatment
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1
2HIPAA PERMITS DISCLOSURE OF POLST TO OTHER HEALTH CARE PROVIDERS AS NECESSARY
Physician Orders for Life-Sustaining Treatment (POLST)
Patient Last Name:
Date Form Prepared:
First
follow
these
orders,
then
contact
Physician/NP/PA
. A copy of the signed POLST
Patient First Name:
Patient Date of Birth:
form is a legally valid physician order. Any section
not completed implies full treatment for that section.
POLST complements an Advance Directive and
Patient Middle Name:
Medical Record #:
(optional)
EMSA #111 B
is not intended to replace that document.
(Effective 1/1/2016)*
C
R
(CPR):
A
ARDIOPULMONARY
ESUSCITATION
If patient has no pulse and is not breathing.
If patient is NOT in cardiopulmonary arrest, follow orders in Sections B and C.
Check
Attempt Resuscitation/CPR
(Selecting CPR in Section A requires selecting Full Treatment in Section B)
One
Do Not Attempt Resuscitation/DNR (Allow Natural Death)
M
I
:
B
EDICAL
NTERVENTIONS
If patient is found with a pulse and/or is breathing.
Full Treatment
– primary goal of prolonging life by all medically effective means.
Check
One
In addition to treatment described in Selective Treatment and Comfort-Focused Treatment, use intubation,
advanced airway interventions, mechanical ventilation, and cardioversion as indicated.
Trial Period of Full Treatment.
Selective Treatment
– goal of treating medical conditions while avoiding burdensome measures.
In addition to treatment described in Comfort-Focused Treatment, use medical treatment, IV antibiotics, and
IV fluids as indicated. Do not intubate. May use non-invasive positive airway pressure. Generally avoid
intensive care.
Request transfer to hospital only if comfort needs cannot be met in current location.
Comfort-Focused Treatment
– primary goal of maximizing comfort.
Relieve pain and suffering with medication by any route as needed; use oxygen, suctioning, and manual
treatment of airway obstruction. Do not use treatments listed in Full and Selective Treatment unless consistent
with comfort goal. Request transfer to hospital only if comfort needs cannot be met in current location.
Additional Orders
:
___________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________
A
A
N
:
C
RTIFICIALLY
DMINISTERED
UTRITION
Offer food by mouth if feasible and desired.
Long-term artificial nutrition, including feeding tubes.
________________________
Additional Orders:
Check
Trial period of artificial nutrition, including feeding tubes. __________________________________________
One
No artificial means of nutrition, including feeding tubes. __________________________________________
I
S
:
D
NFORMATION AND
IGNATURES
Patient (Patient Has Capacity)
Legally Recognized Decisionmaker
Discussed with:
Advance Directive dated _______, available and reviewed
Health Care Agent if named in Advance Directive:
Name: ________________________________________
Advance Directive not available
Phone: _______________________________________
No Advance Directive
Signature of Physician / Nurse Practitioner / Physician Assistant (Physician/NP/PA)
My signature below indicates to the best of my knowledge that these orders are consistent with the patient’s medical condition and preferences.
Print Physician/NP/PA Name:
Physician/NP/PA Phone #:
Physician/PA License #, NP Cert. #:
Physician/NP/PA Signature:
Date:
(required)
Signature of Patient or Legally Recognized Decisionmaker
I am aware that this form is voluntary. By signing this form
the legally recognized decisionmaker acknowledges that this request regarding
,
resuscitative measures is consistent with the known desires of
and with the best interest of, the individual who is the subject of the form.
,
Print Name:
Relationship:
(write self if patient)
Signature:
Date:
(required)
FOR REGISTRY
Mailing Address (street/city/state/zip):
Phone Number:
USE ONLY
SEND FORM WI TH P ATI ENT WHENEVER TR ANSFERR
ED OR DISCH ARGED
*Form versions with effective dates of 1/1/2009, 4/1/2011 or 10/1/2014 are also valid
98458 (1/16)
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