Physician Orders For Life-Sustaining Treatment (Polst) - Florida Page 2
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2HIPAA PERMITS DISCLOSURE OF POLST TO OTHER HEALTH CARE PROVIDERS AS NECESSARY
DOCUMENTATION OF DISCUSSION:
E
Check
Patient (Patient has capacity)
Health Care Representative or surrogate
All
Parent of minor
Court-Appointed Guardian
Other (proxy)
That
Apply
Other Contact Information
Name of Guardian, Surrogate or other Contact Person
Relationship
Phone Number/Address
Name of Health Care Professional Preparing Form
Preparer Title
Phone Number
Date Prepared
Directions for Health Care Professionals
Completing POLST
§
Must be completed by a health care professional based on medical indications, a discussion of treatment benefits and burdens,
and elicitation of patient preferences.
§
POLST must be signed by a MD/DO to be valid. Verbal orders are acceptable with follow-up signature by physician in
accordance with facility/community policy.
§
POLST must be signed by patient/resident or healthcare surrogate/proxy to be valid.
Using POLST
§
Any section of POLST not completed implies full treatment for that section.
§
Use of original form is strongly encouraged. Photocopies and FAXes of signed POLST forms are legal and valid.
§
A semi-automatic external defibrillator (AED) should not be used on a person who has chosen “Do Not Attempt Resuscitation.”
§
Oral fluids and nutrition must always be offered if medically feasible.
§
When comfort cannot be achieved in the current setting, the person, including someone with “comfort measures only,” should be
transferred to a setting able to provide comfort, such as a hospice unit.
§
A person who chooses either “comfort measures only” or “limited additional interventions” should not be entered into a Level I
trauma system.
§
An IV medication to enhance comfort may be appropriate for a person who has chosen “Comfort Measures Only.”
§
A person who desires IV fluids should indicate “Limited Interventions” or “Full Treatment.”
§
A person with capacity or the surrogate/proxy (if patient lacks capacity) can revoke the POLST at any time and request
alternative treatment.
Reviewing POLST
This POLST should be reviewed periodically and a new POLST completed if necessary when:
(1) The person is transferred from one care setting or care level to another, or
(2) There is a substantial change in the person’s health status, or
(3) The person’s treatment preferences change.
To void this form, draw line through sections A through D on page 1 and write “VOID” in large letters.
Review of this POLST Form
Review Date
Reviewer
Location of Review
Review Outcome
No Change
Form Voided
New form completed
No Change
Form Voided
New form completed
No Change
Form Voided
New form completed
SEND FORM WITH PERSON WHENEVER TRANSFERRED OR DISCHARGED
REVISED FORM (JULY 10,2015)
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