Sample Provider Order For Life-Sustaining Treatment (Polst) Utah Life With Dignity Order

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Provider Order for Life-Sustaining Treatment (POLST)
Utah Life with Dignity Order
Bureau of Health Facility Licensing and Certification, Utah Department of Health
State of Utah Rule R432-31 v3.0 December 2014 ( )
U
Patient's Last Name
First Name/Middle Initial
Effective Date of this Order
T
A
Date of Birth
Last 4 of SS#
Address (street/city/state/zip)
H
P
Medical Provider's Name (MD/DO/PA/APRN)
Medical Provider's Phone
O
L
Brief description of patient's
S
medical condition
T
Patient's stated goals
for medical care
U
A. CARDIOPULMONARY RESUSCITATION (CPR)
Treatment options when the patient does not have a pulse and is not breathing (CHECK ONE)
T
Attempt to resuscitate (selecting attempt to resuscitate
Do not attempt or continue any
I do not wish to express a preference (selecting
A
requires selecting full treatment in Section B)
resuscitation (DNR) (Allow Natural Death)
this may lead to attempt to resuscitate)
H
B. MEDICAL INTERVENTIONS
Treatment options when the patient has a pulse and is breathing (CHECK ONE)
FULL TREATMENT: Prolonging life by all medically effective means. Medical care may include endotracheal intubation, mechanical ventilation, defibrillation/
P
cardioversion, vasopressors, and any other life-sustaining care that is required. Also includes medical care described below.
O
LIMITED ADDITIONAL INTERVENTIONS: Treating medical conditions while avoiding burdensome measures. Medical care may include treatment of airway
L
obstruction, bag/valve/mask ventilation, monitoring of cardiac rhythm, IV fluids, IV antibiotics and other medications as indicated. Also includes medical care
S
described below. No endotracheal intubation or mechanical ventilation. Generally avoid the Intensive Care Unit.
COMFORT MEASURES: MAXIMIZING comfort and dignity. Medical care may include oral and body hygiene, reasonable efforts to offer food and fluids orally,
T
medication, oxygen, positioning, warmth and other measures to relieve pain and suffering. Transfer to the hospital only if comfort measures can no longer be
managed at the current setting.
NO PREFERENCE: I do not wish to express a preference (selecting this may lead to full treatment).
U
T
Other Instructions or
clarification; Describe goals
A
and/or time period if a trial
H
intervention is desired:
P
C. ARTIFICIAL NUTRITION
O
Long term artificial nutrition with
Trial period of artificial nutrition with
No artificial nutrition
I do not wish to express a preference
L
feeding tube
feeding tube
S
T
Describe goals and/or time
period if a trial is desired:
D. ADVANCE DIRECTIVE AND PATIENT PREFERENCES
U
T
Advance Directive available, reviewed and confirmed without conflicts
No Advance Directive available
A
H
Health care agent named in Advance Directive
Phone Number
I, the patient, want this order to serve as a general guide. I understand in some situations, the person making decisions
I, the patient, want this order to
P
for me may decide something different if they think it is consistent with my preferences.
be followed strictly.
O
L
Discussed with:
S
T
REQUIRED SIGNATURES
Print Name
Relationship: (write self if patient)
Signature
U
T
Signature of Medical Provider (MD/DO/PA/APRN)
Print Name
License Number
Date
Two signatures required for minors
A
H
P

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