Form Mn PDF Details

In the realm of healthcare, particularly at the juncture of life-sustaining treatment decisions, the Minnesota Provider Orders for Life-Sustaining Treatment (POLST) form stands as a crucial document designed to respect and fulfill the healthcare wishes of patients facing serious illnesses or conditions. This comprehensive order sheet allows for the translation of a patient's preferences into actionable medical orders, ensuring their desires are followed even in critical situations. It covers various facets of care, including decisions about cardiopulmonary resuscitation (CPR), the extent of medical intervention desired, and the use of antibiotics, nutrition, and hydration, thus addressing both comfort-focused care and more aggressive treatments. Unique in its approach, the POLST form vitally includes space for specifying goals of treatment, effectively bridge-building between patient desires and medical possibilities. Authorized healthcare providers can fill out the form, which remains valid in both faxed and photocopied versions, ensuring ease of sharing among relevant healthcare professionals. Significantly, the form can be revisited and revised to keep pace with changes in the patient's condition or wishes, allowing for a dynamic approach to end-of-life care planning. The POLST form, accessible and direct, emphasizes the patient's autonomy and the healthcare system's responsiveness to their individual needs and preferences, marking a respectful step towards personalized medical care.

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Form NameForm Mn
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesmn polst form, mn polst print, mn polst download, minnesota polst

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POLST: Provider Orders for Life Sustaining Treatment POLST

HIPAA PERMITS DISCLOSURE OF POLST TO OTHER HEALTH CARE PROVIDERS AS NECESSARY

PROVIDER ORDERS FOR

LIFE-SUSTAINING TREATMENT (POLST)

FIRST follow these orders,THcontact the patient’s pro.his is a proorder sheet based on the patient’s al condition and wishes. Ptranslates an addirectie into proorders.

An section not co i the aggressie treat

for that section. Patients should alwas be treated with dignitand respect.

Last Name

First/Middle Initial

Date of Birth

Primary Care Provider/Phone

A

CARDIOPULMONARY RESUSCITATION (CPR):

 

 

Patient has no pulse and is not breathing.

 

 

Check

 

 

 

 

 

 

One

 

 

CPR/ATTEMPT RESUSCITATION

 

DNR/DO NOT ATTEMPT RESUSCITATION low atural

 

 

 

 

 

 

An autonal deibrillator or a

 

When not in cardiopulmonary arrest, follow orders in B and C.

 

patient who has chosen “ot Atten.”

 

 

 

 

 

 

 

B

Check

One

Goal

GOALS OF TREATMENT:

Patient has pulse and/or is breathing. See Section A regarding CPR if pulse is lost.

Additional Orders .g. dialsis, etc.

COMFORT CARE ation, oen, oral suction, and clearing of airwas, etc. as needed for iort.

Check all that apply:

InAvoidan emergency,calling 911,callcall_______________________________(e.ginstead.hospice)

If possible, do not transport to ER (when patient can be made comfortable at residence)

If possible, do not admit to the hospital from the ER (e.g. when patient can be made com- fortable at residence)

LIMIT INTERVENTIONS AND TREAT REVERSIBLE CONDITIONS Proentions aieatw or reersible ill

ness / inne threatening chronic conditions. uration of ine or uncoortable interentions should generall be li Transport to R presu

Check one:

Do not intubate

Trial of intubation (e.g.______days) or other instructions: _______________________________________________________

Intubate long-term if necessary

PROVIDE LIFE SUSTAINING TREATMENT

Intubate, cardioert, and proallare to sustain life. Transport to R presu

C

Check

All That

Apply

INTERVENTIONS AND TREATMENT

ANTIBIOTICS (check one):

No Antibiotics se other eliee ser possible. Oral Antibiotics Only o I/I

Use IV/IM Antibiotic Treatment

NUTRITION/HYDRATION (check all that apply):

Additional Orders:

 

 

Offer food and liquids by mouth ral fluids and nutrition ust alwas be

 

 

offered if alleasible

 

Tube feeding through mouth or nose

 

 

Tube feeding directly into GI tract

 

 

IV fluid administration

 

Other:

 

 

 

 

 

Provider Name (MD/DO/ANPRN/PAwhenwhendelegated,areareacceptable)Provider SignatureDate

FAXED COPIES AND PHOTOCOPIES OF THIS FORM ARE VALID.

POLST

TO VOID THIS FORM, DRAW A LINE ACROSS SECTIONS A - D AND WRITE “VOID” IN LARGE LETTERS.

 

 

 

D

SUMMARY OF GOALS

Check

DISCUSSED WITH:

 

 

 

 

 

 

 

All That

 

 

 

PATIENT

 

 

 

 

 

Apply

 

 

 

 

 

 

 

 

PARENT(S) OF MINOR

 

 

 

 

 

 

 

 

 

 

 

 

HEALTH CARE AGENT:

 

 

 

 

 

 

 

 

 

 

 

 

COURT-APPOINTED GUARDIAN

 

 

 

 

 

 

 

 

 

 

 

NONE

 

OTHER:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

POLST

THE BASIS FOR THESE ORDERS IS PATIENT’S (check ALL that apply):

REQUEST

 

 

BEST INTEREST

KNOWN PREFERENCE

 

 

OTHER:

 

 

 

 

HEALTH CARE DIRECTIVE/

 

 

 

 

 

 

LIVING WILL

 

 

 

 

 

 

Name of Health Care Professional Preparing FormPreparer TitlePhone Number Date Prepared

E

 

SIGNATURE OF PATIENT OR HEALTH CARE AGENT / GUARDIAN / SURROGATE

 

THESE ORDERS REFLECT THE PATIENT’S TREATMENT WISHES

 

 

 

 

 

 

 

Name

Date

 

 

 

 

 

 

Relationship to Patient

Phone Number

 

 

 

 

 

 

Signature*

 

 

 

 

 

DIRECTIONS FOR HEALTH CARE PROFESSIONALS

COMPLETING POLST

Must be completed by a health care professional based on patient preferences and medical indications.

If the goal is to support quality of life in last phases of life, then DNust be selected in ection

If the goal is to maintain function and quality of life, then either y be selected in ection

If the goal is to lie as long as possible, then ust be designated in ection

ustPOLSTbe signedmustbybeasignedphysician,by anursephysician,practitioner,advanceDoctorpractice registered ofnurse,y, orDoctorhysicianofheOsteopathy, or Physician Assistant (when signaturedelegated)of.* hetpatientsignatureor ofheaththe carepatientagentor healthdi nogatecare agent/

isguardian/surrogatest ongly encouragedis strongly. encouraged.

USING POLST

ny section of mpleted implies most aggressie treatment for that section.

n automatic enal deibrillator (D) should not be used for a patient hosen “Do Not ttempt n.”

ral luids and nutrition must alys be ofered if medically feasible.

hen comfort cannot be achieed in the current setting, the pa tient, including someone “mfort Measures y,” should

be transferred to a setting able to promfort.

n Iation to enhance comfort may be appropriate for a patient hosen “mfort Measures y”.

tiiciallydministered hydration is a measure h may pro

long life or create complications. eful consideration should be made nsidering this treatment option.

apacity or the surrogate (if patient lacks capac ity) can reoke the y time and request alternatie treatment.

Comfort care only: t this leel, pronly palliatie measures to enhance comfort, minimie pain, reliee distress, aoid ine and perhaps futile medical procedures, all eser patients’ dignity and ing their last moments of life.

his patient must be designated DNn or this choice to be applicable in section .

Limit Interventions and Treat Reversible Conditions: he goal at this leel is to prodditional interentions aimed at

the treatment of neeersible illness or iny or manage

ment of non lifeeatening chronic conditions. reatments may be tried and discontinued if not efectie.

Provide Life-Sustaining Care: he goal at this leel is to pre sere life by prol aal care and ade

support measures easonable and indicated. or patient’s designated DNn e, medical care should

be discontinued at the point of cardio and respiratory arrest.

REVIEWING POLST

his eed periodically and a ne completed if necessary

he patient is transferred from one care setting or leel to another, or

here is a substantial change in the patient’s health status.

mpleted ’s treat

ment preferences change.

MinnesotaPOLST-—August,October,20142011

FAXED COPIES AND PHOTOCOPIES OF THIS FORM ARE VALID.

TO VOID THIS FORM, DRAW A LINE ACROSS SECTIONS A - D AND WRITE “VOID” IN LARGE LETTERS.

POLST

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The best way to complete minnesota polst portion 1

2. The next stage would be to submit the next few blank fields: COMFORT CARE Do not intubate but, In an emergency call eg hospice, fortable at residence, LIMIT INTERVENTIONS AND TREAT, PROVIDE LIFE SUSTAINING TREATMENT, Check All That Apply, INTERVENTIONS AND TREATMENT, and ANTIBIOTICS check one No.

minnesota polst completion process outlined (part 2)

3. This stage is usually easy - fill in every one of the empty fields in NUTRITIONHYDRATION check all that, Additional Orders, offered if medically feasible, Tube feeding through mouth or, Provider Name MDDOAPRNPA when, Provider Signature, Date, and POLST to complete the current step.

Provider Name MDDOAPRNPA when, Date, and POLST in minnesota polst

In terms of Provider Name MDDOAPRNPA when and Date, ensure you get them right here. Both these could be the key fields in the file.

4. You're ready to fill out the next form section! Here you'll have all of these Check All That Apply, DISCUSSED WITH, PATIENT, PARENTS OF MINOR, HEALTH CARE AGENT, COURTAPPOINTED GUARDIAN, NONE, OTHER, POLST, THE BASIS FOR THESE ORDERS IS, REQUEST, BEST INTEREST, KNOWN PREFERENCE, OTHER, and HEALTH CARE DIRECTIVE LIVING WILL empty form fields to fill out.

minnesota polst conclusion process clarified (step 4)

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