Montana Provider Orders For Life-Sustaining Treatment (Polst)

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HIPAA PERMITS DISCLOSURE OF POLST TO OTHER HEALTH CARE PROVIDERS AS NECESSARY
Revised 3/01/2014
Montana Provider Orders For Life-Sustaining Treatment (POLST)
Patient’s Last Name:
THIS FORM MUST BE SIGNED BY A PHYSICIAN, PA or APRN IN
SECTION D TO BE VALID
Patient’s First Name:
If any section is NOT COMPLETE:
Date of Birth:
Provide the most treatment included in that section
Male
Female
EMS: If questions/concerns, contact Medical Control.
Section
Treatment Options:
I
f patient does not have a pulse and is not breathing:
A
Attempt Resuscitation
Do Not Attempt Resuscitation (DNR)
(CPR)
Select only
one box
(Allow Natural Death)
If patient is not in cardiopulmonary arrest, follow orders found in sections B and C
Section
Treatment Options:
If patient has a pulse and/or is breathing:
B
Comfort Measures ONLY: Relieve pain and suffering through the use of medication by any route, positioning,
Select only
wound care or other measures. Use oxygen, suction and manual treatment of airway obstruction as needed for
one box
comfort. Transfer to hospital ONLY if comfort needs cannot be met in current location.
Limited Additional Interventions: In addition to the care described above, use medical treatment, IV fluids and
cardiac monitoring as indicated. Do not use intubation, advanced airway interventions or mechanical interventions.
May consider use of less invasive airway support such as CPAP or BiPAP. Transfer to hospital if indicated for
treatment or comfort. Generally Avoid Intensive Care.
Full Treatment: In addition to the care described above, use intubation, advanced airway interventions,
mechanical ventilation and cardioversion as indicated. Transfer to hospital if indicated. Include Intensive Care.
Other Instructions: ___________________________________________________________________________
Section
Artificially Administered Nutrition:
(Offer food and fluid by mouth if feasible and/or desired)
C
No Artificial Nutrition by Tube.
Select only
one box
Defined trial period of Artificial Nutrition by Tube. Specifically: _________________________________
Long Term Artificial Nutrition by Tube.
Section
Discussed With:
Patient
Health Care Agent or Decision-Maker
Court Appointed Guardian
D
Select box(es)
Other ________________________________________
By signing below, the decision-maker acknowledges that these orders are consistent with the known desires of the
patient.
Signature of Patient or Decision-Maker (required)
Printed Name
Relationship if not Patient
Name of Person Preparing Form
Phone Number of Preparer
Date Form Prepared
Signature of Provider: My signature below indicates to the best of my knowledge that these orders are consistent with the medical
conditions and preferences of the patient.
Signature of Physician, PA, or APRN (required)
Printed Name of Physician, PA or APRN
Date and Time
Provider Phone Number
FORM SHALL ACCOMPANY PATIENT WHENEVER TRANSFERRED CARE LEVELS OR TO HOME
Use of the original form is strongly encouraged. Photocopy, fax or electronic copies of signed POLST forms are legal and valid.

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