HIPAA PERMITS DISCLOSURE TO HEALTH CARE PROFESSIONALS AS NECESSARY FOR TREATMENT
for Life-Sustaining Treatment (POLST)
First follow these orders, then contact physician,
Last Name / First / Middle Initial
NP or PA. These medical orders are based on the
patient’s current medical condition and
preferences. Any section not completed does not
City / State / Zip:
invalidate the form and implies full treatment for
Date of Birth:
Patient has no pulse and is not breathing.
__Attempt Resuscitation/CPR __ Do Not Attempt Resuscitation/DNR (Allow Natural Death)
When not in cardiopulmonary arrest, follow orders in B, C and D.
Patient 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, suction and manual treatment of airway obstruction as needed for
Do Not Transfer to Hospital for life sustaining treatment.
Transfer if comfort needs cannot be met in current setting.
__Limited Additional Interventions: Includes all care described above. Use medical treatment and
monitoring as indicated. Do not use intubation, advanced airway interventions, or mechanical ventilation.
May consider less invasive airway support (e.g. CPAP, BiPAP). Transfer to hospital if indicated. Avoid
__Full Treatment: Includes all care described above. Use intubation, advanced airway interventions,
mechanical ventilation, and cardioversion as indicated. Transfer to hospital if indicated. Includes
__No antibiotics. Use other measures to relieve symptoms.
__Determine use or limitation of antibiotics when infection occurs.
__Use antibiotics if medically indicated.
ffer food / liquids by mouth if feasible.
Part 1 – Nutrition:
Part 2 – Hydration:
__No artificial nutrition by tube
__No artificially administered fluids
__Trial period of artificial nutrition by tube.
__Trial period of artificial hydration.
__Long-term artificial nutrition by tube.
__Full treatment with artificially administered fluids.
BASIS FOR ORDERS
My signature below indicates to the best of my knowledge that these orders are consistent with the patient’s
current medical condition and preferences as indicated by:
Basis for determining patient’s preferences (
Discussion with: (
check all that apply
check all that apply
__Advance Directive (on file)
__Parent of a minor
__Patient’s current statement to Physician /NP/ PA
__Patient’s statement to authorized representative
__ Best interest determined by authorized representative (no
__ Health Care Agent
advance directive / preferences unknown)
Print Name of Primary Care Professional
Print Name of Signing Physician / PA/ NP
Signature of Physician / PA /NP (required)