Wyopolst Providers Orders For Life Sustaining Treatment Page 2
ADVERTISEMENT
1
2HIPAA PERMITS DISCLOSURE TO HEALTHCARE PROFESSIONALS AS NECESSARY FOR TREATMENT
WyoPOLST
Providers Orders for Life Sustaining Treatment
–
Patient Name (Last, First Middle)
Date of Birth:
Gender:
Additional Contact Information (optional)
Name of Next of Kin, Guardian, Surrogate, or Patient Contact:
Relationship:
Phone Number:
Patient has: ☐ Advanced Directive (or Living Will)
☐ DPOAHC
Encourage all advance care planning documents
☐ Organ Donor
to accompany POLST
Directions for Health Care Professional
Completing WyoPOLST
Completion of WyoPOLST form is VOLUNTARY.
WyoPOLST is recommended for patients with advanced illness or frailty.
Must be completed by Wyoming Licensed Health Care Professional based on patient preferences and medical indications.
WyoPOLST must be signed by a licensed provider and the patient/decisionmaker to be valid. Verbal orders are
acceptable with follow-up signature by licensed provider in accordance with facility/community policy.
Use of original form is strongly encouraged. Original form should be printed on yellow card-stock, and orignal form should
accompany patient. Photocopies and FAXes of signed WyoPOLST forms are legal and valid.
Additional copies of the WyoPOLST form can be obtained by contacting the Wyoming Department of Health, Aging
Division, Community Living Section at 1-800-442-2766.
Using WyoPOLST
Any incomplete section of WyoPOLST implies full treatment for that section.
Section A:
No defibrillator (including AED) should be used on a person who has chosen “Do Not Attempt Resuscitation.”
Section B:
Comfort-Focused therapies must always be offered to any patient regardless of level of care selected.
When comfort cannot be achieved in the current setting, the person, including someone with “Comfort Focused Therapy”
should be transferred to a setting able to provide comfort (e.g., treatment of a hip fracture).
IV medication to enhance comfort may be appropriate for a person who has chosen “Comfort Focused Therapy”
Non-invasive airway techniques includes continuous positive airway pressure (CPAP), bi-level positive airway pressure
(BiPAP), and bag valve mask (BVM) assisted respirations.
Treatment of dehydration prolongs life. A person who desires IV fluids should indicate “Selective Treatment” or “Full
Treatment.”
Section C:
Oral fluids and nutrition must always be offered if medically feasible.
Reviewing WyoPOLST
It is recommended that WyoPOLST be reviewed periodically. Review is recommended when:
The person is transferred from one care setting or care level to another, or
There is a substantial change in the person’s health status, or
The person’s treatment preferences change.
Modifying and Voiding WyoPOLST
A person with capacity can, at any time, void the WyoPOLST form or change his/her mind about his/her treatment
preferences by executing a verbal or written advance directive or a new WyoPOLST form.
To void WyoPOLST, draw a line through Sections A through D and write “VOID” in large letters. Sign and date this line.
Review of WyoPOLST:
Review Date
Reviewer Name/Signature
Reason for Review
Review Outcome
☐ Change in Patient Status
☐ No Change
☐ Transfer
☐ Form Voided
☐ Annual Review
☐ New Form Completed
☐ Change in Patient Status
☐ Change in Patient Status
☐ Transfer
☐ Transfer
☐ Annual Review
☐ Annual Review
Form Updated 09/2015
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal