Montana Provider Orders For Life-Sustaining Treatment
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2HIPAA PERMITS DISCLOSURE OF POLST TO OTHER HEALTH CARE PROVIDERS AS NECESSARY
Montana Provider Orders For Life-Sustaining Treatment (POLST)
Patient’s Last Name:
THIS FORM MUST BE SIGNED BY A PHYSICIAN, PA or APRN IN SECTION E TO BE VALID
f any section is NOT COMPLETE:
I
Patient’s First Name:
Provide the most treatment included in that section
Date of Birth:
EMS: If questions/concerns, contact Medical Control.
Male
Female
Section
Cardiopulmonary Resuscitation:
If patient does not have a pulse and/or is not breathing:
A
Resuscitate
Do Not Resuscitate
(Full Code)
(No Code)
(Allow Natural Death)(Comfort One)
Select only
Patient does not want any heroic or
one box
Life-saving measures.
If patient is not in cardiopulmonary arrest, follow orders found in section B and C
Section
Medical Interventions:
If patient has a pulse and/or is breathing:
B
Comfort Measures: Please treat patient with dignity and respect. Reasonable measures are to be made to
offer food and fluids by mouth and attention must be paid to hygiene. Medication, positioning, wound care, and
Select only
other measures shall be used to relieve pain and discomfort. Use oxygen, suction and manual treatment of airway
one box
obstruction as needed for comfort. EMS: Patient prefers no transfer to hospital for life-sustaining treatment.
Transfer if comfort needs cannot be met in current location.
Limited Additional Interventions: In addition to the care described above, cardiac monitoring and oral/IV
medications may be provided. EMS: Transfer to hospital if indicated, do not perform intubation or advanced airway
interventions. Hospital: Do not admit to Intensive Care.
Full Treatment: In addition to the care described above, endotracheal intubation, advanced airway interventions,
mechanical ventilation, defibrillation and cardioversion may be provided. Hospital: Admit to Intensive Care if
indicated.
Other Instructions:
Artificial Fluids and Nutrition:
Antibiotics and Blood Products:
Section
Feeding tube
No Feeding tube
Antibiotics
No Antibiotics
C
IV fluid
No IV fluid
Blood Products
No Blood Products
May select
Other Instructions:
Other Instructions:
more than
one
Section
Advance Directives: The following documents also exist:
Living Will
Other _________________________________________________
D
_________________________________________________________________________
Section
Patient or Surrogate Signature: ________________________________ Date:_____________
E
(by signing the POLST, I agree that this POLST supersedes my living will, if the two conflict)
Print Patient or Surrogate (person with authority under 50-9-106, MCA)
Name:________________________________
Relationship:___________________
Physician/APRN/PA (in consultation with supervising physician) Signature: ________________ Date:_______
Print Physician/APRN/PA Name : ______________________________ MT License Number: _________________
Contact Phone Number: _________________ Discussed with:
Patient
Spouse
Other __________
The basis for these orders is:
Patient’s request
Patient’s known preference
____________________
FORM SHALL ACCOMPANY PATIENT WHENEVER TRANSFERRED OR DISCHARGED
Use of original form is strongly encouraged. Photocopy, fax or electronic copies of signed POLST forms are legal and valid
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