New Hampshire Polst Form
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1
2NEW HAMPSHIRE
02/2013
HIPAA PERMITS DISCLOSURE TO HEALTHCARE PROFESSIONALS AS NECESSARY FOR TREATMENT
Provider Orders for Life-Sustaining Treatment
Last Name of Patient
(POLST)
This is a Physician/APRN Order Sheet. First follow these orders,
First Name/Middle Initial for Patient
then contact physician or APRN. These medical orders are based
on the patient’s current medical condition and preferences. Any
Date of Birth (mm/dd/yyyy)
Last 4 SSN
Gender
section not completed does not invalidate the form and implies
M
F
full treatment for that section.
_______, ______, ________
Section
Cardiopulmonary Resuscitation (CPR): Patient has no pulse or is not breathing.
A
Attempt CPR
Check
One
Do Not Resuscitate/DNR
(
The PINK Portable-DNR must accompany the POLST for DNR to be in effect in all NH settings.)
Follow orders in B, C and D when not in cardiopulmonary arrest.
Medical Interventions: Patient has pulse and/or is breathing.
Section
Full Treatment –
Includes care described below, Use intubation, advanced airway interventions, mechanical
B
ventilation, and cardioversion as indicated. Transfer to hospital if indicated. Includes intensive care.
Limited Interventions –
Includes care described below. Use medical treatment, IV fluids and cardiac monitor as
Check
indicated. Do not use intubation, advanced airway interventions, or mechanical ventilation. May consider less invasive airway
One
support (e.g. CPAP, BiPAP). Transfer to hospital level of care to meet need, if indicated. Avoid intensive care.
Comfort-focused Care –
Use medication by any route, positioning, wound care and other measures to relieve pain
and discomfort. Use oxygen, suction and manual treatment of airway obstruction as needed. Patient prefers no transfer to
hospital for life-sustaining treatment. Transfer to more acute level if comfort needs cannot be met in current location.
Other Instructions:_______________________________________________________________________________________________
Section
Medically Administered Fluids and Nutrition. Oral fluids and nutrition must be offered if medically feasible and consistent
with patient’s goals of care.
C
IV fluids long-term
Feeding tube long-term
Check
Only
IV fluids for a defined trial period
Feeding tube for a defined trial period
One
(provide other measures to assure comfort)
in Each
No IV Fluids (provide other measures to assure comfort)
No feeding tube
Column
Other Instructions:________________________________________________________________________________________________
Section
Antibiotics if indicated clinically or by testing.
Antibiotics only if likely to contribute to comfort
D
No antibiotics
Check One
Other Instructions:________________________________________________________________________________________________
Section
Discussed with:
The basis for these orders is:
E
Patient
Patient’s preference
DPOAH representative
Activated Durable Power of Attorney for Healthcare (DPOAH)
Check All
Court-appointed guardian
Activated Living Will
That
Parent(s) of minor
Parent of Minor
Apply
Other:________________________(specify)
Guardianship
Other:________________________(specify)
Date of Discussion:
Documentation of discussion is located in medical chart at:
Mandatory Signature of Patient or DPOAH, Guardian or Parent of Minor, and Physician/ARPN
Name (Print)
Signature (Mandatory)
Date
Relationship
(write “self” if patient)
Physician/APRN Name: (Print)
Physician/APRN Phone Number:
Physician/APRN
State License
Number:
Physician/APRN Signature: (Mandatory)
Date:
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