Mississippi Physician Orders For Sustaining Treatment (Post) Form
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1
2MISSISSIPPI PHYSICIAN ORDERS FOR SUSTAINING TREATMENT (POST)
Patient Last Name
Patient First Name/Middle
This document is based on this person’s current medical condition and wishes and
is to be reviewed for potential replacement in the case of a substantial change in
either
Patient Date of Birth
Effective Date
(Form must be
HIPAA permits disclosure of POST to other health professionals as necessary
reviewed at least annually)
Any section not completed indicates preference for full treatment for that section
C
R
(CPR):
Patient has no pulse AND is not breathing.
ARDIOPULMONARY
ESUSCITATION
A
Attempt Resuscitation (CPR)
Check one
Do Not Attempt Resuscitation (DNR)
When not in cardiopulmonary arrest, follow orders in B, C, and D.
M
I
:
If the patient has pulse AND breathing OR has pulse and is NOT breathing.
EDICAL
NTERVENTIONS
B
Full Sustaining Treatment:
Transfer to a hospital if indicated. Includes intensive care. Treatment Plan: Full treatment
Check One
including life support measures. Provide treatment including the use of intubation, advanced airway interventions, mechanical
ventilation, defibrillation or cardioversion as indicated, medical treatment, intravenous fluids, and comfort measures.
Limited Interventions:
Transfer to a hospital if indicated. Avoid intensive care. Treatment Plan: Provide basic medical
treatments. In addition to care described in Comfort Measures below, provide the use of medical treatment; oral and
intravenous medications; intravenous fluids; cardiac monitoring as indicated; noninvasive bi-level positive airway pressure; a
bag valve mask. This option excludes the use of intubation or mechanical ventilation.
ADDITIONAL ORDERS: (e.g., vasopressors, dialysis, etc.)______________________________________________________
Comfort Measures Only
: Treatment Goal: Maximize comfort through use of medication by any route; keeping the patient
clean, warm, and dry; positioning, wound care, and other measures to relieve pain and suffering; and the use of oxygen,
suction, and manual treatment of airway obstruction as needed for comfort. Do not transfer to a hospital unless comfort
needs cannot be met in the patient’s current location (e.g., hip fracture).
Other instructions:___________________________________________________________________________________
A
:
C
NTIBIOTICS
Use antibiotics if life can be sustained
Check One
Determine use or limitation of antibiotics when infection occurs
Use antibiotics only to relieve pain and discomfort
Other Instructions_________________________________________________
M
A
F
N
:
Administer oral fluids and nutrition if physically possible.
EDICALLY
DMINISTERED
LUIDS AND
UTRITION
D
Directing the administration of nutrition into blood vessels if physically feasible as determined in accordance with reasonable medical
Check One
judgment by selecting one (1) of the following:
in Each of
Total parenteral nutrition, long-term if indicated.
the 3
Total parenteral nutrition for a defined trial period. Goal: ______________________
Categories
No parenteral nutrition.
Directing the administration of nutrition by feeding tube if physically feasible as determined in accordance with reasonable medical
judgment by selecting one (1) of the following:
Long-term feeding tube if indicated
Feeding tube for a defined trial period. Goal: ________________________
No feeding tube
OTHER INSTRUCTIONS ________________________________________________________
Directing the administration of hydration if physically feasible as determined in accordance with reasonable medical judgment by
selecting one (1) of the following
Long-term intravenous fluids if indicated
Intravenous fluids for a defined trial period. Goal: _________________________
Intravenous fluids only to relieve pain and discomfort
P
P
B
POST F
(T
)
E
ATIENT
REFERENCES AS A
ASIS FOR THIS
ORM
HIS SECTION TO BE FILLED OUT WITH PATIENT DIRECTION
Patient has an advance healthcare directive (per statute § 41-41-203):
YES , Date of Execution: _____________
Check All
I certify that the Physician Order for Sustaining Treatment is in accordance with the advance directive.
That Apply
Signature:_________________________
Print Name:____________________________ Relationship:_____________________
Patient is an unemancipated minor, direction was provided by the following in accordance with §41-41-3, Mississippi Code of
1972:
Minor’s guardian or custodian
Minor’s parent
Adult brother or sister of the minor
Minor’s grandparent, or
Adult who has exhibited special care and concern for minor
Patient is an adult or an emancipated minor, direction was provided by the following in accordance with §41-41-205, 41-41-211
or 41-41-213, Mississippi Code of 1972:
Patient
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