Wyopolst Providers Orders For Life Sustaining Treatment

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WyoPOLST
Providers Orders for Life Sustaining Treatment
HIPAA PERMITS DISCLOSURE TO HEALTHCARE PROFESSIONALS AS NECESSARY FOR TREATMENT
Last / First / Middle Name
(Place ID Sticker Here if Applicable):
FIRST follow these orders, THEN contact the Physician, PA,
or APRN. This is a Provider Order Sheet based on the
person’s current medical condition and wishes. Any section
not completed implies full treatment for that section. Every
Date of Birth:
Last 4 SSN:
Gender:
patient shall be treated with dignity and respect.
____/_____/_____
___ ___ ___ ___
M /
F
A
CARDIOPULMONARY RESUSCITATION (CPR): Person has no pulse and is not breathing.
Check
☐ CPR / Attempt Resuscitation
☐ DNR / Do Not Attempt Resuscitation (Allow Natural Death)
One
When NOT in cardiopulmonary arrest, follow orders in B and C
B
MEDICAL INTERVENTIONS: Person has pulse and/or is breathing.
☐ FULL TREATMENT: Use intubation, advanced airway interventions, mechanical ventilation and
Check
One
defibrillation/cardioversion as indicated. Includes care described below.
Transfer to hospital if indicated. Includes intensive care.
☐ SELECTIVE TREATMENT: Use medical treatment, IV fluids, and cardiac monitor as indicated. Do not
use intubation or mechanical ventilation. May use less invasive airway support (e.g. CPAP, BIPAP). Includes
treatments listed below. Includes care described below.
Transfer to hospital if indicated. Avoid intensive care if possible.
☐ COMFORT-FOCUSED THERAPY: Use medication by any route, positioning, wound care and other
measures to relieve pain and suffering. Use oxygen, oral suction and manual treatment of airway obstruction
as needed for comfort.
Patient prefers no transfer: Transfer if comfort needs cannot be met in current location.
Additional Orders (e.g. dialysis, etc) _________________________________________________________________
ARTIFICIALLY ADMINISTERED NUTRITION: Oral fluids and nutrition must always be offered if medically
C
feasible.
Check
☐ Long-term artificial nutrition by tube
One
☐ Trial period of artificial nutrition by tube
☐ No artificial nutrition by tube
Additional Orders/Patient Goals: ____________________________________________________________________
D
MEDICAL CONDITION / PATIENT GOALS:
E
___ In initialing this line, I indicate that my instructions on this POLST form may not be changed by my next of kin or
medical decision maker if I am incapacitated.
SIGNATURES: The signatures below verify that these orders are consistent with the patient’s medical condition,
known preferences, and best known information.
Discussed with:
Print Primary Health Care Provider Name and Address:
Phone #:
☐ Patient
☐ Parent of a minor
Primary Health Care Provider Signature:
Date:
☐ Legal Guardian
☐ Health Care Agent (DPOAHC)
☐ Spouse
Patient (or Legal Representative):
Date:
☐ Other: _________________
SEND ORIGINAL FORM WITH PERSON WHENEVER TRANSFERRED OR DISCHARGED
Use of original form is strongly encouraged, however photocopies and faxes of signed POLST forms are legal and valid.

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