Pennsylvania Orders For Life-Sustaining Treatment (Polst)

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SEND FORM WITH PERSON WHENEVER TRANSFERRED OR DISCHARGED
To follow these orders, an EMS provider must have an order from his/her medical command physician
Last Name
Pennsylvania
First/Middle Initial
Orders for Life-Sustaining
Treatment (POLST)
Date of Birth
FIRST follow these orders, THEN contact physician, certified registered nurse practitioner or physician assistant. This is an Order Sheet based on the
person’s medical condition and wishes at the time the orders were issued. Everyone shall be treated with dignity and respect.
C
R
ARDIOPULMONARY
ESUSCITATION (CPR): Person has no pulse and is not breathing.
A
CPR/Attempt Resuscitation
DNR/Do Not Attempt Resuscitation (Allow Natural Death)
Check
One
When not in cardiopulmonary arrest, follow orders in B, C and D.
M
I
EDICAL
NTERVENTIONS: Person has pulse and/or is breathing.
COMFORT MEASURES ONLY 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.
Do not transfer to hospital for life-sustaining treatment. Transfer if comfort needs cannot be met in current
location.
LIMITED ADDITIONAL INTERVENTIONS Includes care described above. Use medical treatment, IV fluids and
B
cardiac monitor as indicated. Do not use intubation, advanced airway interventions, or mechanical ventilation.
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Transfer to hospital if indicated. Avoid intensive care if possible.
One
FULL TREATMENT Includes care described above. Use intubation, advanced airway interventions, mechanical
ventilation, and cardioversion as indicated.
Transfer to hospital if indicated. Includes intensive care.
_______________________________________________________________
Additional Orders
A
A
H
N
RTIFICIALLY
DMINISTERED
YDRATION /
UTRITION:
A
NTIBIOTICS:
Always offer food and liquids by mouth if feasible
No antibiotics. Use other measures to relieve
No hydration and artificial nutrition by tube.
symptoms.
C
D
Determine use or limitation of antibiotics when
Trial period of artificial hydration and nutrition by tube.
infection occurs, with comfort as goal
Check
Check
One
One
Use antibiotics if life can be prolonged
Long-term artificial hydration and nutrition by tube.
Additional Orders
Additional Orders
SUMMARY OF GOALS, MEDICAL CONDITION AND SIGNATURES:
Patient Goals/Medical Condition:
Discussed with
Patient
Parent of Minor
Health Care Agent
Health Care Representative
Court-Appointed Guardian
Other:
E
By signing this form, I acknowledge that this request regarding resuscitative measures is consistent with the known
Check
desires of, and in the best interest of, the individual who is the subject of the form.
One
Physician /PA/CRNP Printed Name:
Physician /PA/CRNP Phone Number
Physician/PA/CRNP Signature (Required):
D
ATE
Signature of Patient or Surrogate
Relationship (write “self” if patient)
Signature (required)
Name (print)
PaDOH version 10-14-10
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