Louisiana Physician Orders For Scope Of Treatment (Lapost)
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2HIPAA PERMITS DISCLOSURE OF LaPOST TO OTHER HEALTH CARE PROVIDERS AS NECESSARY
LOUISIANA PHYSICIAN ORDERS FOR SCOPE OF TREATMENT (LaPOST)
FIRST follow these orders, THEN contact physician. This is a
LAST NAME
Physician Order form based on the person’s medical condition
_________________________________________________________________
and preferences. Any section not completed implies full treatment
FIRST NAME/MIDDLE NAME
for that section. LaPOST complements an Advance Directive
and is not intended to replace that document. Everyone shall be
_________________________________________________________________
treated with dignity and respect. Please see for
DATE OF BIRTH
MEDICAL RECORD NUMBER (optional)
information regarding “what my cultural/religious heritage tells me
_________________________________________________________________
about end of life care.”
PATIENT’S DIAGNOSIS OF LIFE LIMITING DISEASE AND
GOALS OF CARE:
IRREVERSIBLE CONDITION:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
A.
CARDIOPULMONARY RESUSCITATION (CPR):
PERSON IS UNRESPONSIVE, PULSELESS AND IS NOT bREATHINg
CPR/Attempt Resuscitation (requires full treatment in section b)
CHECk
When not in cardiopulmonary arrest, follow orders in B and C.
DNR/Do Not Attempt Resuscitation (Allow Natural Death)
ONE
B.
MEDICAL INTERVENTIONS:
PERSON HAS PULSE OR IS bREATHINg
FULL TREATMENT
(primary goal of prolonging life by all medically effective means) Use treatments in Selective Treatment and Comfort Focused treatment.
Use mechanical ventilation, advanced airway interventions and cardioversion if indicated.
CHECk
SELECTIVE TREATMENT
(primary goal of treating medical conditions while avoiding burdensome treatments) Use treatments in Comfort Focused
ONE
treatment. Use medical treatment, including antibiotics and IV fluids as indicated. May use non invasive positive airway pressure (CPAP/biPAP).
Do not intubate. generally avoid intensive care.
COMFORT FOCUSED TREATMENT
(primary goal is maximizing comfort) Use medication by any route to provide pain and symptom management.
Use oxygen, suctioning and manual treatment of airway obstruction as needed to relieve symptoms. (Do not use treatments listed in full or selective treatment
unless consistent with goals of care. Transfer to hospital ONLY if comfort focused treatment cannot be provided in current setting.)
ADDITIONAL ORDERS:
(e.g. dialysis, etc.)
__________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
Medically assisted nutrition and hydration is optional when it
• cannot reasonably be expected to prolong life • would be more burdensome than beneficial • would cause significant physical discomfort
C.
ARTIFICIALLY ADMINISTERED FLUIDS AND NUTRITION:
(Always offer food/fluids by mouth as tolerated)
No artificial nutrition by tube.
CHECk
Trial period of artificial nutrition by tube. (Goal: ___________________________________________________________________________________ )
ONE
Long-term artificial nutrition by tube. (If needed)
D.
SUMMARY
Discussed with:
Patient (Patient has capacity)
Personal Health Care Representative (PHCR)
The basis for these orders is:
Patient’s declaration (can be oral or nonverbal)
Advance Directive dated ________________ , available and reviewed
CHECk
ALL
Patient’s Personal Health Care Representative
Advance Directive not available
THAT
APPLY
(Qualified Patient without capacity)
No Advance Directive
Patient’s Advance Directive, if indicated, patient has completed
Health care agent if named in Advance Directive:
an additional document that provides guidance for treatment
Name: __________________________________________________________
measures if he/she loses medical decision-making capacity.
Resuscitation would be medically non-beneficial.
Phone: _________________________________________________________
This form is voluntary and the signatures below indicate that the physician orders are consistent with the patient’s medical condition and
treatment plan and are the known desires or in the best interest of the patient who is the subject of the document.
PRINT PHYSICIAN’S NAME
PHYSICIAN SIgNATURE (MANDATORY)
PHYSICIAN PHONE NUMbER
DATE (MANDATORY)
PRINT PATIENT OR PHCR NAME
PATIENT OR PHCR SIgNATURE (MANDATORY)
DATE (MANDATORY)
PHCR RELATIONSHIP
PHCR ADDRESS
PHCR PHONE NUMbER
SEND FORM WITH PERSON WHENEVER TRANSFERRED OR DISCHARGED
USE OF ORIGINAL FORM IS STRONGLY ENCOURAGED. PHOTOCOPIES AND FAXES OF SIGNED LaPOST FORMS ARE LEGAL AND VALID.
V2.06.13.2016
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