Physician Orders For Life-Sustaining Treatment (Polst) Form Page 2
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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 2: Patient Preferences
Section
ORGAN DONATION
D
❏ I do not wish to donate my organs
Organ
❏ I wish to donate any organs deemed useful
Donation
Other Instructions: ______________________________________________________________
Section
The following documents/persons have further information regarding patient’s/resident’s
E
preferences:
Advance
1. Advance Directive (AD): Living Will, Declaration, Durable Power of Attorney for Health Care
Directive
❏ NO
❏ YES
If no AD skip to 2 below
AD Registered with Secretary of State:
❏ NO
❏ YES - Registration no.:___________________
Other location: _____________________________________________
Appointed agent #1: _______________________________ Telephone No: ___________________
Appointed agent #2: _______________________________ Telephone No: ____________________
2. If no AD contact: __________________________________ Telephone No: ____________________
3. Court-Appointed Guardian
❏ NO
❏ YES
Name: __________________________
Telephone No: ___________________
Section
Patient / Health Care Agent (Durable Power of Attorney) / Guardian (circle one) Approval
F
I have discussed this form, its treatment options and their implications for sustaining life with my / the
patient’s health care provider. This form reflects my treatment preferences.
Signatures
Signature: _______________________________________________________ Date: _____________
The preferences of Sections A and B above were also discussed with and understood by:
❏ Spouse
❏ Adult child
❏ Court-Appointed Guardian
❏ Parent of Minor
❏ Health Care Agent (DPOA)
Other: ___________________
Witnessed by (any checked above): ___________________________________ Date: _____________
Preparer’s Information
Preparer’s Name (print) ____________________________________________ Date: ___________
Signature of Person Preparing Form ___________________________________________________
For Internal Use
GENERAL INSTRUCTIONS
Record all treatments entered on this POLST as orders in patient’s chart.
Copy POLST form for patient record.
If orders change complete a new POLST and write VOID across this POLST.
Transfer or discharge patient with a current POLST form.
WHEN THIS FORM SHOULD BE REVIEWED
This form (POLST) should be reviewed periodically and if:
The patient/resident is transferred from one care setting or care level to another,
•
or
There is a substantial change in patient/resident health status, or
•
The patient/resident treatment preferences change.
•
Send original with patient when transferred or discharged
COPY FOR ARCHIVAL PURPOSES ONLY
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