8/9/2019 Polst Form

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Pyca Odfor Life-Sustaining Treatment (POLST)Last Name /First/Middle Initial

Date of Birth

A

First ollow these orders, then contact physician, nurse practitioner orPA-C. This is a Physician Order Sheet based on the persons current medicalcondition and wishes. Any section not completed implies ull treatmentor that section. Everyone shall be treated with dignity and respect.

Medical condition/Goals:

cardiopulMonary

resuscitation

(cpr): Person has no pulse and is not breathing.

Medical interventions: Person has pulse and/or is breathing.

antibiotics:

Comfort measures only Use medication by any route, positioning, wound care and other measuresto relieve pain and suering. Use oxygen, oral suction and manual treatment o airway obstruction asneeded or comort. Patient prefers no transfer: EMS contact medical control to determine iftransport indicated to provide adequate comfort.

CPR/Attempt Resuscitation DNR/Do Not Attempt Resuscitation (Allow Natural Death)

When not in cardiopulmonary arrest, ollow orders in B, C and D.

limited additional interventions Includes care described above. Use medical treatment, IV uids andcardiac monitor as indicated. Do not use intubation or mechanical ventilation. May use less invasive air-

way support (e.g. CPAP, BiPAP). Transferto hospital if indicated. Avoid intensive care if possible.

full treatment Includes care described above. Use intubation, advanced airway interventions, mechanicalventilation, and cardioversion as indicated. Transferto hospital if indicated. Includes intensive care.

No antibiotics. Use other measures to relievesymptoms.

Determine use or limitation o antibiotics

when inection occurs, with comort as goal.Use antibiotics i lie can be prolonged.

Additional Orders: (e.g. dialysis, etc.) _________________________________________________________

_____________________________________________________________________________________

Additional Orders: ________________________

______________________________________

No artifcial nutrition by tube.

Trial period o artifcial nutrition by tube.

(Goal: _____________________________________________________________________)

Long-term artifcial nutrition by tube.

artificially adMinisterednutrition:Always oer ood and liquids by mouth i easible.

Check

One

hiPAA PerMits DisCLOsUre OF POLst tO Other heALth CAre PrOViDers As neCessArY

BCheck

One

CCheck

One

DCheck

One

e

Use o original orm is strongly encouraged. Photocopies and FAXes o signed POLST orms are legal and valid

senD FOrM With PersOn WheneVer trAnsFerreD Or DisChArGeD

Last 4 #SSN Gender

M F

Additional Orders: ________________________

______________________________________

Dcud w:

Patient Parent o Minor

Legal Guardian

Health Care Agent (DPOAHC)

Spouse/Other:

_________________________________

PRINT Physician/ARNP/PA-C Name

Physician/ARNP/PA-C Signature (mandatory)

Patient or Legal Surrogate Signature (mandatory)

Phone Number

Date

siGnatures

: The signatures below veriy that these orders are consistent with the patients medical

Date

F condition, known preerences and best known inormation:

8/9/2019 Polst Form

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O Coac ifomao (Opoal)

senD FOrM With PersOn WheneVer trAnsFerreD Or DisChArGeD

hiPAA PerMits DisCLOsUre OF POLst tO Other heALth CAre PrOViDers As neCessArY

directionsforHealtH care professionalsCpg Polst

Must be completed by health care proessional.

Should reect persons current preerences and medical indications. Encourage completion o an advance directive.

POLST must be signed by a physician/NP/PA to be valid. Verbal orders are acceptable with ollow-up signature byphysician/NP/PA in accordance with acility/community policy.

Use o original orm is encouraged. Photocopies and FAXes o signed POLST orms are legal and valid.

ug PolstAny incomplete section of POLST implies full treatment for that section.

SECTION A: No defbrillator (including AEDs) should be used on a person who has chosen Do Not Attempt Resuscitation.

SECTION B: When comort cannot be achieved in the current setting, the person, including someone with Comort Measures

Only, should be transerred to a setting able to provide comort (e.g., treatment o a hip racture).

An IV medication to enhance comort may be appropriate or a person who has chosen Comort Measures Only.

Treatment o dehydration is a measure which may prolong lie. A person who desires IV uids should indicateLimited Additional Interventions or Full Treatment.

SECTION D: Oral uids and nutrition must always be oered i medically easible.

A person with capacity or the surrogate o a person without capacity, can void the orm and request alternative treatment.

rwg Polst

This POLST should be reviewed periodically whenever:

(1) The person is transerred rom one care setting or care level to another, or

(2) There is a substantial change in the persons health status, or

(3) The persons treatment preerences change.

To void this orm, draw line through Physician Orders and write VOID in large letters. Any changes require a new POLST.

Name o Health Care Proessional Preparing Form Preparer Title Date Prepared

Relationship Phone Number

Phone Number

Name o Guardian, Surrogate or other Contact Person

Revised December 20

rvw of POLst Fom

No Change

Form Voided New orm completed

Reviewer Location o ReviewReview Date Review Outcome

No Change

Form Voided New orm completed

Person has: Health Care Directive (living will) DPOAHC Living WillRegistry

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