Pennsylvania Orders For Life-Sustaining Treatment (Polst) (Page 2 of 2) in pdf

SEND FORM WITH PERSON WHENEVER TRANSFERRED OR DISCHARGED

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Surrogate

Relationship

Phone Number

Health Care Professional Preparing Form

Preparer Title

Phone Number

Date Prepared

Directions for Healthcare Professionals

Any individual for whom a Pennsylvania Order for Life-Sustaining Treatment form is completed should ideally have an advance health care

directive that provides instructions for the individual’s health care and appoints an agent to make medical decisions whenever the patient is

unable to make or communicate a healthcare decision. If the patient wants a DNR Order issued in section “A”, the physician/PA/CRNP

should discuss the issuance of an Out-of-Hospital DNR order, if the individual is eligible, to assure that an EMS provider can honor his/her

wishes. Contact the Pennsylvania Department of Aging for information about sample forms for advance health care directives. Contact the

Pennsylvania Department of Health, Bureau of EMS, for information about Out-of Hospital Do-Not-Resuscitate orders, bracelets and

necklaces. POLST forms may be obtained online from the Pennsylvania Department of Health.

Completing POLST

Must be completed by a health care professional based on patient preferences and medical indications or decisions

by the patient or a surrogate. This document refers to the person for whom the orders are issued as the “individual”

or “patient” and refers to any other person authorized to make healthcare decisions for the patient covered by this

document as the “surrogate.”

At the time a POLST is completed, any current advance directive, if available, must be reviewed.

Must be signed by a physician/PA/CRNP and patient/surrogate to be valid. Verbal orders are acceptable with follow-

up signature by physician/PA/CRNP in accordance with facility/community policy. A person designated by the patient

or surrogate may document the patient’s or surrogate’s agreement. Use of original form is strongly encouraged.

Photocopies and Faxes of signed POLST forms should be respected where necessary

Using POLST

If a person’s condition changes and time permits, the patient or surrogate must be contacted to assure that the

POLST is updated as appropriate.

If any section is not completed, then the healthcare provider should follow other appropriate methods to determine

treatment.

An automated external defibrillator (AED) should not be used on a person who has chosen “Do Not Attempt

Resuscitation”

Oral fluids and nutrition must always be offered if medically feasible.

When comfort cannot be achieved in the current setting, the person, including someone with “comfort measures

only,” should be transferred to a setting able to provide comfort (e.g., treatment of a hip fracture).

A person who chooses either “comfort measures only” or “limited additional interventions” may not require transfer or

referral to a facility with a higher level of care.

An IV medication to enhance comfort may be appropriate for a person who has chosen “Comfort Measures Only.”

Treatment of dehydration is a measure which may prolong life. A person who desires IV fluids should indicate

“Limited Additional Interventions” or “Full Treatment.

A patient with or without capacity or the surrogate who gave consent to this order or who is otherwise specifically

authorized to do so, can revoke consent to any part of this order providing for the withholding or withdrawal of life-

sustaining treatment, at any time, and request alternative treatment.

Review

This form should be reviewed periodically (consider at least annually) and a new form completed if necessary when:

(1) The person is transferred from one care setting or care level to another, or

(2) There is a substantial change in the person’s health status, or

(3) The person’s treatment preferences change.

Revoking POLST

If the POLST becomes invalid or is replaced by an updated version, draw a line through sections A through E of the

invalid POLST, write “VOID” in large letters across the form, and sign and date the form.

PaDOH version 10-14-10

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Pennsylvania Orders For Life-Sustaining Treatment (Polst) Page 2

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