New Jersey Practitioner Orders For Life-Sustaining Treatment (Polst)
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2HIPAA PERMITS DISCLOSURE OF POLST TO OTHER HEALTHCARE PROFESSIONALS AS NECESSARY
NEW JERSEY PRACTITIONER ORDERS FOR LIFE-SUSTAINING TREATMENT (POLST)
Follow these orders, then contact physician/APN. This Medical Order Sheet is based on the current medical condition of the person referenced below and
their wishes stated verbally or in a written advance directive. Any section not completed implies full treatment for that section. Everyone will be treated with
dignity and respect.
Person Name (last, first, middle)
Date of Birth
GOALS OF CARE
(See reverse for instructions. This section does not constitute a medical order.)
A
MEDICAL INTERVENTIONS:
Person is breathing and/or has a pulse
Full Treatment. Use all appropriate medical and surgical interventions as indicated to support life. If in a nursing facility, transfer to
hospital if indicated. See section D for resuscitation status.
Limited Treatment. Use appropriate medical treatment such as antibiotics and IV fluids as indicated. May use non-invasive positive
airway pressure. Generally avoid intensive care.
B
Transfer to hospital for medical inter ventions.
Transfer to hospital only if comfort needs cannot be met in current location.
Symptom Treatment Only. Use aggressive comfort treatment to relieve pain and suffering by using any medication by any route,
positioning, wound care and other measures. Use oxygen, suctioning and manual treatment of airway obstruction as needed for
comfort. Use Antibiotics only to promote comfort. Transfer only if comfort needs cannot be met in current location.
Additional Orders: ________________________________________________________________________________________________
ARTIFICIALLY ADMINISTERED FLUIDS AND NUTRITION:
C
Always offer food/fluids by mouth if feasible and desired.
Defined trial period of artificial nutrition.
No artificial nutrition.
Long-term artificial nutrition.
CARDIOPULMONARY RESUSCITATION (CPR)
AIRWAY MANAGEMENT
Person has no pulse and/or is not breathing
Person is in respiratory distress with a pulse
D
Attempt resuscitation/CPR
Intubate/use artificial ventilation as needed
Do not attempt resuscitation/DNAR
Do not intubate - Use O2, manual treatment to
Allow Natural Death
relieve airway obstruction, medications for comfort.
If I lose my decision-making capacity, I authorize my surrogate decision maker, listed below, to modify or revoke the NJ POLST orders in
consultation with my treating physician/APN.
Yes
No
E
Print
Name of Surrogate (address on reverse)
Phone Number
SIGNATURES:
Has the person named above made an anatomical gift:
I have discussed this information with my physician/APN.
Yes
No
Unknown
Signature________________________________________________
These orders are consistent with the person’s medical condition,
Person Named Above
known preferences and best known information.
F
Health Care Representative/Legal Guardian
Spouse/Civil Union Partner
PRINT - Physician/APN Name
Phone Number
Parent of Minor
Other Surrogate______________________________________
Physician/APN Signature (Mandatory)
Date/Time
SEND ORIGINAL FORM WITH PERSON WHENEVER TRANSFERRED
10/8/12
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