Provider Orders For Life-Sustaining Treatment (Polst) - Hawaii
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1
2HIPAA PERMITS DISCLOSURE OF POLST TO OTHER HEALTH CARE PROFESSIONALS AS NECESSARY
PROVIDER ORDERS FOR LIFE-SUSTAINING TREATMENT (POLST) - HAWAI‘I
Patient’s Last Name
FIRST follow these orders. THEN contact the
patient’s provider. This Provider Order form is
based on the person’s current medical condition
First/Middle Name
and wishes. Any section not completed implies
full treatment for that section. Everyone shall be
Date of Birth
Date Form Prepared
treated with dignity and respect.
A
CARDIOPULMONARY RESUSCITATION (CPR):
** Person has no pulse and is not breathing **
Attempt Resuscitation/CPR
Do Not Attempt Resuscitation/DNAR
A
N
D
(
llow
atural
eath)
Check
(Section B: Full Treatment required)
One
B
C
If the patient has a pulse, then follow orders in
and
.
B
MEDICAL INTERVENTIONS:
** Person has pulse and/or is breathing **
Comfort Measures Only
Use medication by any route, positioning, wound care and other measures to relieve pain
Check
and suffering. Use oxygen, suction and manual treatment of airway obstruction as needed for comfort. Transfer if comfort
needs cannot be met in current location.
One
Limited Additional Interventions
Includes care described above. Use medical treatment, antibiotics, and IV fluids
as indicated. Do not intubate. May use less invasive airway support (e.g. continuous or bi-level positive airway pressure).
Transfer to hospital if indicated. Avoid intensive care.
Full Treatment
Includes care described above. Use intubation, advanced airway interventions, mechanical ventilation,
and defibrillation/cardioversion as indicated. Transfer to hospital if indicated. Includes intensive care.
Additional Orders
:
C
ARTIFICIALLY ADMINISTERED NUTRITION:
Always offer food and liquid by mouth if feasible
and desired
.
(See Directions on next page for information on nutrition & hydration)
Check
No artificial nutrition by tube.
Defined trial period of artificial nutrition by tube.
Goal:
One
Long-term artificial nutrition by tube.
Additional Orders:
SIGNATURES AND SUMMARY OF MEDICAL CONDITION
- Discussed with:
D
Patient or
Legally Authorized Representative (LAR). If LAR is checked, you must check one of the boxes below:
Check
Guardian
Agent designated in Power of Attorney for Healthcare
Patient-designated surrogate
One
Surrogate selected by consensus of interested persons (Sign section E)
Parent of a Minor
Signature of Provider (Physician/APRN licensed in the state of Hawai‘i.)
My signature below indicates to the best of my knowledge that these orders are consistent with the person’s medical
condition and preferences.
Print Provider Name
Provider Phone Number
Date
Provider Signature (required)
Provider License #
Signature of Patient or Legally Authorized Representative
My signature below indicates that these orders/resuscitative measures are consistent with my wishes or (if signed by LAR) the
known wishes and/or in the best interests of the patient who is the subject of this form.
Signature (required)
Name (print)
Relationship (write ‘self’ if patient)
Summary of Medical Condition
Official Use Only
SEND FORM WITH PERSON WHENEVER TRANSFERRED OR DISCHARGED
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