Physician Orders For Life-Sustaining Treatment (Polst)
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1
2HIPAA PERMITS DISCLOSURE OF POLST TO OTHER HEALTH CARE PROVIDERS AS NECESSARY
Physician Orders for Life-Sustaining Treatment (POLST)
Patient Last Name:
Date Form Prepared:
First follow these orders, then contact physician.
A copy of the signed POLST form is a legally valid
Patient First Name:
Patient Date of Birth:
physician order. Any section not completed implies
full treatment for that section. POLST complements
an Advance Directive and is not intended to
Patient Middle Name:
Medical Record #:
EMSA #111 B
(optional)
replace that document.
(Effective 10/1/2014)*
A
C
r
(CPR):
If patient has no pulse and is not breathing.
ardIopulmonary
eSuSCItatIon
If patient is NOT in cardiopulmonary arrest, follow orders in Sections B and C.
Check
o
Attempt Resuscitation/CPR
(Selecting CPR in Section A requires selecting Full Treatment in Section B)
One
o
Do Not Attempt Resuscitation/DNR
(Allow Natural Death)
m
I
:
B
If patient is found with a pulse and/or is breathing.
edICal
nterventIonS
o
Full Treatment
– primary goal of prolonging life by all medically effective means.
Check
In addition to treatment described in Selective Treatment and Comfort-Focused Treatment, use intubation,
One
advanced airway interventions, mechanical ventilation, and cardioversion as indicated.
o
Trial Period of Full Treatment.
o
Selective Treatment
– goal of treating medical conditions while avoiding burdensome measures.
In addition to treatment described in Comfort-Focused Treatment, use medical treatment, IV antibiotics, and IV
fluids as indicated. Do not intubate. May use non-invasive positive airway pressure. Generally avoid intensive care.
o
Request transfer to hospital only if comfort needs cannot be met in current location.
o
Comfort-Focused Treatment
– primary goal of maximizing comfort.
Relieve pain and suffering with medication by any route as needed; use oxygen, suctioning, and manual treatment
of airway obstruction. Do not use treatments listed in Full and Selective Treatment unless consistent with comfort
goal. Request transfer to hospital only if comfort needs cannot be met in current location.
Additional Orders:
C
a
a
n
:
Offer food by mouth if feasible and desired.
rtIfICIally
dmInIStered
utrItIon
o Long-term artificial nutrition, including feeding tubes.
Additional Orders:
Check
o Trial period of artificial nutrition, including feeding tubes.
One
o No artificial means of nutrition, including feeding tubes.
D
I
S
:
nformatIon and
IgnatureS
Discussed with:
o Patient (Patient Has Capacity)
o Legally Recognized Decisionmaker
o Advance Directive dated ________, available and reviewed à
Health Care Agent if named in Advance Directive:
o Advance Directive not available
Name:
o No Advance Directive
Phone:
Signature of Physician
My signature below indicates to the best of my knowledge that these orders are consistent with the person’s medical condition and preferences.
Print Physician Name:
Physician Phone Number:
Physician License Number:
Physician Signature:
Date:
(required)
Signature of Patient or Legally Recognized Decisionmaker
I am aware that this form is voluntary. By signing this form, the legally recognized decisionmaker acknowledges that this request regarding
resuscitative measures is consistent with the known desires of, and with the best interest of, the individual who is the subject of the form.
Print Name:
Relationship:
(write self if patient)
Signature:
Date:
(required)
Mailing Address (street/city/state/zip):
Phone Number:
Office Use Only:
SEND FORM WITH PATIENT WHENEVER TRANSFERRED OR DISCHARGED
*Form versions with effective dates of 1/1/2009 or 4/1/2011 are also valid
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