Hawaii Polst Form – Fill Out and Use This PDF

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

PROVIDER ORDERS FOR LIFE-SUSTAINING TREATMENT (POLST) - HAWAI‘I

	FIRST follow these orders. THEN contact the			Paient’s Last Name
	paient’s provider. This Provider Order form is
	based on the person’s current medical condiion
				First/Middle Name
	and wishes. Any secion not completed implies
	full treatment for that secion. 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 **
	Atempt Resuscitaion/CPR	Do Not Atempt Resuscitaion/DNAR (Allow Natural Death)
Check	(Secion B: Full Treatment required)
One
	If the paient has a pulse, then follow orders in B and C.
B	MEDICAL INTERVENTIONS:		** Person has pulse and/or is breathing **
	Comfort Measures Only Use medicaion by any route, posiioning, wound care and other measures to relieve pain
Check	and suffering. Use oxygen, sucion and manual treatment of airway obstrucion as needed for comfort. TRANSFER IF COMFORT
One	needs cannot be met in current locaion.

Limited Addiional Intervenions Includes care described above. Use medical treatment, anibioics, and IV fluids as indicated. Do not intubate. May use less invasive airway support (e.g. coninuous or bi-level posiive airway pressure). TRANSFER to hospital if indicated. Avoid intensive care.

Full Treatment Includes care described above. Use intubaion, advanced airway intervenions, mechanical venilaion, and defibrillaion/cardioversion as indicated. TRANSFER to hospital if indicated. Includes intensive care.

Addiional Orders:

C	ARTIFICIALLY ADMINISTERED NUTRITION: Always offer food and liquid by mouth if feasible
	(See Direcions on next page for informaion on nutriion & hydraion)				and desired.
Check	No arificial nutriion by tube.		Defined trial period of arificial nutriion by tube.
One	Long-term arificial nutriion by tube.		Goal:
	Addiional Orders:
D	SIGNATURES AND SUMMARY OF MEDICAL CONDITION - Discussed with:
	Paient or	Legally Authorized Representaive (LAR). If LAR is checked, you must check one of the boxes below:
Check
	Guardian	Agent designated in Power of Atorney for Healthcare			Paient-designated surrogate
One
	Surrogate selected by consensus of interested persons (Sign secion 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 condiion and preferences.

Print Provider Name	Provider Phone Number	Date
Provider Signature (required)	Provider License #

Signature of Paient or Legally Authorized Representaive

My signature below indicates that these orders/resuscitaive measures are consistent with my wishes or (if signed by LAR) the known wishes and/or in the best interests of the paient who is the subject of this form.

Signature (required)

Name (print)

Relaionship (write ‘self’ if paient)

SEND FORM WITH PERSON WHENEVER TRANSFERRED OR DISCHARGED

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

Patient’s Preferred Emergency Contact or Legally Authorized Representative

Name	Address		Phone Number
Health Care Professional Preparing Form	Preparer Title	Phone Number	Date Form Prepared

E	SURROGATE SELECTED BY CONSENSUS OF INTERESTED PERSONS
	(Legally Authorized Representaive as outlined in secion D)
	I make this declaraion under the penalty of false swearing to establish my authority to act as the legally authorized represen-
	taive for the paient named on this form. The paient has been determined by the primary physician to lack decisional

capacity and no health care agent or court appointed guardian or paient-designated surrogate has been appointed or the agent or guardian or designated surrogate is not reasonably available. The primary physician or the physician’s designee has made reasonable efforts to locate as many interested persons as pracicable and has informed such persons of the paient's lack of capacity and that a surrogate decision-maker should be selected for the paient. As a result I have been selected to act as the paient’s surrogate decision-maker in accordance with Hawai‘i Revised Statutes §327E-5. I have read secion C below and understand the limitaions regarding decisions to withhold or to withdraw arificial hydraion and nutriion.

	Signature (required)	Name	Relaionship

•Must be completed by health care professional based on paient preferences and medical indicaions.

•POLST must be signed by a Physician or Advanced Pracice Registered Nurse (APRN) licensed in the state of Hawai‘i and the paient or the paient’s legally authorized representaive to be valid. Verbal orders by providers are not acceptable.

•Use of original form is strongly encouraged. Photocopies and FAXes of signed POLST forms are legal and valid.

Using POLST

• Any incomplete secion of POLST implies full treatment for that secion. Secion A:

• No defibrillator (including automated external defibrillators) should be used on a person who has chosen “Do Not Atempt Resuscitaion.”

Secion B:

•When comfort cannot be achieved in the current seing, the person, including someone with “Comfort Measures Only,” should be transferred to a seing able to provide comfort (e.g., treatment of a hip fracture).

•IV medicaion to enhance comfort may be appropriate for a person who has chosen “Comfort Measures Only.”

•A person who desires IV fluids should indicate “Limited Intervenions” or “Full Treatment.”

Secion C:

• A paient or a legally authorized representaive may make decisions regarding arficial nutriion or hydraion. However, a surrogate who has not been designated by the paient (surrogate selected by consensus of interested persons) may only make a decision to withhold or withdraw arificial nutriion and hydraion when the primary physician and a second independent physician cerify in the paient’s medical records that the provision or coninuaion of arificial nutriion or hydraion is merely prolonging the act of dying and the paient is highly unlikely to have any neurological response in the future. HRS §327E-5.

Reviewing POLST

It is recommended that POLST be reviewed periodically. Review is recommended when:

•The person is transferred from one care seing or care level to another, or

•There is a substanial change in the person’s health status, or

•The person’s treatment preferences change.

Modifying and Voiding POLST

•A person with capacity or, if lacking capacity the legally authorized representaive, can request a different treatment plan and may revoke the POLST at any ime and in any manner that communicates an intenion as to this change.

•To void or modify a POLST form, draw a line through Secions A through E and write “VOID” in large leters on the original and all copies. Sign and date this line. Complete a new POLST form indicaing the modificaions.

•The paient’s provider may medically evaluate the paient and recommend new orders based on the paient’s current health status and goals of care.

Kōkua Mau – Hawai‘i Hospice and Palliaive Care Organizaion

Kōkua Mau is the lead agency for implementaion of POLST in Hawai‘i. Visit www.kokuamau.org/polst to download a copy

or find more POLST informaion. This form has been adopted by the Department of Health July 2014

Kōkua Mau • PO Box 62155 • Honolulu HI 96839 • info@kokuamau.org • www.kokuamau.org

SEND FORM WITH PERSON WHENEVER TRANSFERRED OR DISCHARGED