Sample Provider Order For Life-Sustaining Treatment (Polst) Utah Life With Dignity Order Page 2
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2Provider 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 ( )
DIRECTIONS FOR HEALTHCARE PROVIDERS
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COMPLETING POLST
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- This form is intended for both adult and pediatric patients.
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- The POLST is not an Advance Directive and does not replace it. The POLST is a Medical Order.
- When available, review the Advance Directive and POLST form to ensure consistency.
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- The POLST must be completed by a medical provider (MD/DO/PA/APRN) based on patient preferences and medical indications.
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- The entire form should be completed. A patient may indicate that they “do not wish to express a preference” rather than leaving a
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section of the form blank.
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- Section D, which indicates the degree of leeway the patient would like to grant their surrogate, must be completed by the
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individual patient and only if the patient has medical decision-making capacity.
- The POLST must be signed by the patient or surrogate decision maker AND by a medical provider (MD/DO/PA/APRN) to be valid.
In the case of pediatric patients, signatures from two different medical providers are required.
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- Verbal orders are acceptable with follow up signature in accordance with organization/community policy.
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- Use of the original form is strongly encouraged. Photocopies and FAXs of signed POLST forms are legal and valid.
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USING POLST
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Section A:
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- If a patient has selected “Do Not Attempt Resuscitation” and is found pulse less and not breathing, no defibrillator (including
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automated external defibrillators) or chest compressions should be used.
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Section B:
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- A person may chose “DNR” in Section A and “Full Treatment” in Section B, recognizing in Section A the setting refers to where
there are no signs of life (palpable pulse) and Section B refers to the setting where there are signs of life.
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- Choosing “Attempt to resuscitate” in Section A requires “Full treatment” in Section B as an attempt at resuscitation may include
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endotracheal intubation, mechanical ventilation, defibrillation/ cardioversion, and/or vasopressors.
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- When comfort cannot be achieved in the current setting, the patient, including someone with “Comfort Measures,” may be
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transferred to the hospital to provide comfort (e.g., treatment of hip fracture).
- If a patient has indicated that he/she would not want to return to the hospital, this should be written in the “other instructions and
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clarifications” section of the form.
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- IV antibiotics and fluids are generally not considered “Comfort Measures” and may prolong life. A person who desires IV fluids or IV
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antibiotics should indicate “Limited Additional Interventions” or “Full Treatment.”
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- Some IV medications (e.g. medication for pain, nausea, delirium, etc.) may be appropriate for a patient who has chosen “Comfort
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Measures.”
REVIEWING POLST
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This form should be reviewed periodically (consider at least annually). Review is also recommended when:
- The patient is transferred from one care setting or care level to another.
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- There is a substantial change in the patient’s health status.
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- The patient’s treatment preferences change.
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MODIFYING AND VOIDING POLST
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- The POLST form can be modified at any time if a patient changes his/her mind about his/her treatment preferences by completing
a new POLST form.
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- If a patient has given sufficient leeway to his/her surrogate to modify the POLST form, any modifications made should be
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consistent with patient preferences and in collaboration with the medical provider.
- It is recommended that revocation of the form be documented by drawing a line through sections A through D, writing “VOID” in
large letters, and signing/dating the form.
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- The most recently dated POLST is considered the valid POLST. The most recently dated POLST orders supersede all prior POLST
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directives.
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