Form 111913 - Nevada Physician Order For Life-Sustaining Treatment - Sample
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1
2Please contact your physician to complete your Nevada POLST form
NEVADA POLST (Physician Order for Life-Sustaining Treatment)
HIPAA PERMITS DISCLOSURE TO HEALTH CARE PROFESSIONALS & ELECTRONIC REGISTRY
Faxed, copied or electronic versions of a Nevada POLST are legal and valid
SIDE 1: Medical Orders
Last Name/First/Middle Initial
Consult this form when patient lacks decisional
capacity. It is intended to be honored by any health-
care provider who treats the patient in any health-care
setting, including, without limitation, a residence, health
Date of Birth (dd/mm/yr)
Last 4 SSN
Gender
care facility or the scene of a medical emergency (NRS
M
449.694.). A section not completed does not invalidate
F
/
/
the rest and indicates full treatment for that section.
___ ___ ___ ___
Patient/resident has no pulse & is not breathing.
CARDIOPULMONARY RESUSCITATION (CPR).
Section
Attempt Resuscitation (CPR)
Allow Natural Death (Do Not Attempt Resuscitation)
A
(See Section B: Full Treatment required)
If available, EMS-DNR #:_____________________
CPR
When not in cardiopulmonary arrest follow orders in Section B
Check one only
Patient/resident has pulse and/or is breathing.
MEDICAL INTERVENTIONS.
Section
Life-sustaining treatment may be ordered for a trial period to determine if there is benefit to the
B
patient. If a life-sustaining treatment is started, but turns out not to be helpful, the treatment can be
Interventions
stopped.
1.
Comfort Measures Only. The patient/resident is treated with dignity, respect and kept
clean, warm and dry. Reasonable measures are made to offer food and fluids by mouth as tolerated,
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.
Transfer only if comfort needs cannot be met in current location.
Other Instructions:_________________________________________________________________
2. Limited Medical Interventions. Comfort measures always provided.
a. Life-Sustaining Antibiotics.
No antibiotics. Use other measures to relieve symptoms
Administer antibiotics by mouth as necessary
Administer antibiotics IV as necessary
Other Instructions:_______________________________________________________________
b. Artificially Administered Fluids and Nutrition.
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:______________________________________________________________
c. Other Limitations of Medical Interventions.
No intensive care admission
No lab work
No x-ray
No antiarrhythmic drugs
No IV (assure agreement with a. & b. above)
No dialysis
No hyperalimentation
No electrolyte or acid/base corrective measures
Other Instructions:_____________________________________________________________
3.
Full Treatment. Includes care above plus endotracheal intubation and cardioversion.
Additional Instructions:
___________________________________________________
Date (Required)
Physician Signature (Required)
Physician Name (Print)
Section
C
Physician Office Address
Physician Phone
Physician License No.
Physician
Signature
Send original with patient when discharged or transferred
NEVADA FORM 111913
Approved December 2013
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