Physician Orders For Life-Sustaining Treatment (Polst)-Florida
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2HIPAA PERMITS DISCLOSURE TO HEALTH CARE PROFESSIONALS AS NECESSARY FOR TREATMENT
Physician Orders for Life-Sustaining Treatment (POLST)-Florida
Follow these orders until orders are
Patient Last Name
Patient First Name
Middle Int.
reviewed. These medical orders are
based on the patient’s current medical
Date of Birth: (mm/dd/yyyy)
Gender
Last 4 SSN:
condition and preferences. Any section
M
. F
not completed does not invalidate the
form and implies full treatment for that
If the patient has decision-making capacity, the patient’s presently
section.
With
significant
change
of
expressed wishes should guide his or her treatment
condition new orders may need to be
written.
CARDIOPULMONARY RESUSCITATION (CPR): Patient is unresponsive, pulseless, and not breathing.
A
Check
Attempt Resuscitation/CPR
One
Do Not Attempt Resuscitation/DNR
When not in cardiopulmonary arrest, follow orders in B and C.
MEDICAL INTERVENTIONS: If patient has pulse and is breathing.
B
Check
Full Treatment – goal is to prolong life by all medically effective means.
One
In addition to care described in Comfort Measures Only and Limited Additional Interventions, use intubation, advanced airway interventions,
and mechanical ventilation as indicated. Transfer to hospital and /or intensive care unit if indicated.
Care Plan: Full treatment including life support measures in the intensive care unit.
Limited Medical Interventions – goal is to treat medical conditions but avoid burdensome measures
In addition to care described in Comfort Measures Only, use medical treatment, antibiotics, IV fluids and cardiac monitor as indicated. No
intubation, advanced airway interventions, or mechanical ventilation. May consider less invasive airway support (e.g. CPAP, BiPAP).
Transfer to hospital if indicated. Generally avoid the intensive care unit.
Care Plan: Provide basic medical treatments.
Comfort Measures Only (Allow Natural Death) – goal is to maximize comfort and avoid suffering
Relieve pain and suffering through the use of any medication by any route, positioning, wound care and other measures. Use oxygen,
suction and manual treatment of airway obstruction as needed for comfort. Patient prefers no transfer to hospital for life-sustaining
treatments. Transfer if comfort needs cannot be met in current location. Consider hospice or palliative care referral if appropriate.
Care Plan: Maximize comfort through symptom management.
Additional Orders:
C
ARTIFICIALLY ADMINISTERED NUTRITION: Offer food by mouth if feasible.
Check
Long-term artificial nutrition by tube.
Additional Instructions: _________________________
One
Defined trial period of artificial nutrition by tube.
___________________________________________
No artificial nutrition by tube.
___________________________________________
D
HOSPICE or PALLIATIVE CARE (complete if applicable) - consider referral as appropriate
Check
Patient/Resident Currently enrolled
Patient/Resident Currently enrolled
Not indicated or refused
One
in Hospice Care
in Palliative Care
Contact:________________________
Contact:________________________
Print Physician Name
MD/DO License #
Phone Number
Physician Signature (mandatory)
Date
Print Patient/Resident or Surrogate/Proxy Name
Relationship (write ‘self’ if patient)
Patient or Surrogate Signature (mandatory)
Date
SEND FORM WITH PATIENT WHENEVER TRANFERRED OR DISCHARGED
Use of original form is strongly encouraged. Photocopies and facsimiles of completed POLST are legal and valid.
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