Physician Orders For Life-Sustaining Treatment (Polst) Form
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2NEVADA Physician Orders for Life-Sustaining Treatment (POLST)
HIPAA Permits Disclosure to Health Care Professionals & Electronic Registry As Needed For Treatment
SIDE 1: Medical Orders
Follow these orders until orders change. These medical
Last Name/First/Middle Initial
orders are based on the patient’s current medical condition
and preferences. When the need arises, this form should
Date of Birth (dd/mm/yr)
Last 4 SSN
Gender
guide treatment decisions. Any section not completed does
M
not invalidate the form and implies full treatment for that
/
/
F
section.
___ ___ ___ ___
Section
Patient/resident has no pulse and is not breathing
Cardiopulmonary Resuscitation (CPR).
A
❏ Attempt Resuscitation (CPR)
❏ Do Not Attempt Resuscitate (Allow Natural Death)
CPR
(See Section B: Full Treatment required)
If available, EMS-DNR #_____________________
Check one
❏ Limited Medical Intervention: See Section B
only
When not in cardiopulmonary arrest follow orders in Section B
Section
MEDICAL INTERVENTIONS. Patient/resident has pulse and/or is breathing
B
1. ❏ Comfort Measures Only. The patient/resident is treated with dignity, respect and kept clean,
Interventions
warm and dry. Reasonable measures are made to offer food and fluids by mouth, and attention is paid
to hygiene. Medication, positioning, wound care and other measures are used to relieve pain and
suffering. Oxygen, suction and manual treatment of airway obstruction may be used as needed for
comfort. These measures are to be used where the patient/resident lives. The patient/resident is not
to be hospitalized unless comfort measures are not successful.
Other Instructions: _____________________________________________________________
2. Life-Sustaining Antibiotics
❏ No antibiotics. Use other measures to relieve symptoms
❏ Administer antibiotics by mouth as necessary
❏ Administer antibiotics IV as necessary
Other instructions____________________________________________________________
3. Administration of Fluids and Nutrition. Comfort measures always provided.
❏ No feeding tube
❏ No IV fluids
❏ Defined trial period of feeding tube
❏ Defined trial period of IV fluids
❏ Long term feeding tube
❏ Long term IV fluids
Other Instructions:___________________________________________________________
4. Other Limitations of Medical Interventions
❏ No intensive care admission
❏ No lab work
❏ No x-ray
❏ No antiarrhythmic drugs
❏ No IV (assure agreement with 2 & 3 above)
❏ No dialysis
❏ No hyperalimentation
❏ Other instructions :
❏ No electrolyte or acid/base corrective
____________________________________
measures
____________________________________
5. ❏ Full Treatment. Includes care above plus endotracheal intubation and cardioversion.
Date
Physician Signature
Physician Name (print)
Section
C
Physician Office Address
Physician Phone
Physician
Signature
Send original with patient when discharged or transferred
COPY FOR ARCHIVAL PURPOSES ONLY
EXHIBIT B – HEALTH CARE
Document consists of 2 pages.
Entire exhibit provided.
Meeting Date: 07-10-12
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