Form Mn – Fill Out and Use This PDF

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

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:

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

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.

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