Hipaa Physician Orders For Life-Sustaining Treatment
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hiPAA PerMits DisCLOsUre OF POLst tO Other heALth CAre PrOViDers As neCessArY
Physician Orders
for Life-Sustaining Treatment
First follow these orders, then contact physician, nurse practitioner
Last Name - First Name - Middle Initial
or PA-C. The POLST form is always voluntary. The POLST is a set
of medical orders intended to guide medical treatment based on
a person’s current medical condition and goals. Any section not
Date of Birth
Last 4 #SSN
Gender
completed implies full treatment for that section. Everyone shall be
M
F
treated with dignity and respect.
Agency Info/Sticker
Medical Conditions/Patient Goals:
A
C
r
(Cpr):
ardiopulmonary
esusCitation
Person has no pulse and is not breathing.
CPR/Attempt Resuscitation
DNAR/Do Not Attempt Resuscitation (Allow Natural Death)
Check
One
Choosing DnAr will include appropriate comfort measures and may still include the range of
treatments below. When not in cardiopulmonary arrest, go to part B.
B
m
i
:
ediCal
nterventions
Person has pulse and/or is breathing.
Check
Comfort measures only Use medication by any route, positioning, wound care and other measures
One
to relieve pain and suffering. Use oxygen, oral suction and manual treatment of airway obstruction as
needed for comfort.
Patient prefers no hospital transfer : EMS contact medical control to deter-
mine if transport indicated to provide adequate comfort.
limited additional interventions Includes care described above. Use medical treatment, IV fluids and
cardiac monitor as indicated. Do not use intubation or mechanical ventilation. May use less invasive air-
way support (e.g. CPAP, BiPAP).
Transfer to hospital if indicated. Avoid intensive care if possible.
full treatment Includes care described above. Use intubation, advanced airway interventions, mechanical
ventilation, and cardioversion as indicated.
Transfer to hospital if indicated. Includes intensive care.
Additional Orders: (e.g. dialysis, etc.) _________________________________________________________
C
s
:
ignatures
The signatures below verify that these orders are consistent with the patient’s medical
condition, known preferences and best known information. If signed by a surrogate, the
patient must be decisionally incapacitated and the person signing is the legal surrogate.
Discussed with:
PRINT — Physician/ARNP/PA-C Name
Phone Number
Patient
Parent of Minor
Guardian with Health Care Authority
Physician/ARNP/PA-C Signature (mandatory)
Date (mandatory)
Spouse/Other as authorized by RCW 7.70.065
Health Care Agent (DPOAHC)
PRINT — Patient or Legal Surrogate Name
Phone Number
Patient or Legal Surrogate Signature (mandatory)
Date (mandatory)
Person has:
Health Care Directive (living will)
encourage all advance care planning
documents to accompany POLst
Durable Power of Attorney for Health Care
senD OriGinAL FOrM With PersOn WheneVer trAnsFerreD Or DisChArGeD
Photocopies and faxes of signed POLST forms are legal and valid. May make copies for records.
Revised 4/2014
For more information on POLST visit
See back of form for non-emergency preferences
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