HIPAA 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
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:
CARDIOPULMONARY RESUSCITATION (CPR):
PERSON IS UNRESPONSIVE, PULSELESS AND IS NOT bREATHINg
CPR/Attempt Resuscitation (requires full treatment in section b)
When not in cardiopulmonary arrest, follow orders in B and C.
DNR/Do Not Attempt Resuscitation (Allow Natural Death)
PERSON HAS PULSE OR IS bREATHINg
(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.
(primary goal of treating medical conditions while avoiding burdensome treatments) Use treatments in Comfort Focused
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.)
(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
ARTIFICIALLY ADMINISTERED FLUIDS AND NUTRITION:
(Always offer food/fluids by mouth as tolerated)
No artificial nutrition by tube.
Trial period of artificial nutrition by tube. (Goal: ___________________________________________________________________________________ )
Long-term artificial nutrition by tube. (If needed)
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
Patient’s Personal Health Care Representative
Advance Directive not available
(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
measures if he/she loses medical decision-making capacity.
Resuscitation would be medically non-beneficial.
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
PRINT PATIENT OR PHCR NAME
PATIENT OR PHCR SIgNATURE (MANDATORY)
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.