Page 124 - Dementia-Care-Specialist-Toolkit
P. 124

HIPAA PERMITS DISCLOSURE OF POLST TO OTHER HEALTH CARE PROVIDERS AS NECESSARY
                         Physician Orders for Life-Sustaining Treatment (POLST)

                         First  follow  these  orders,  then  contact  Patient Last Name:    Date Form Prepared:
                         Physician/NP/PA. A copy of the signed POLST
                         form is a legally valid physician order. Any section  Patient First Name:  Patient Date of Birth:
                         not completed implies full treatment for that section.
        EMSA #111 B      POLST complements an  Advance Directive and  Patient Middle Name:   Medical Record #: (optional)
              e
                4
            t
             i
             v
                1
                /
                   17)
                  2
                 /
            c
        ( (Effective 4/1/2017)**  is not intended to replace that document.
         Ef
                  0
           e
          f
         A     CARDIOPULMONARY RESUSCITATION (CPR):                    If patient has no pulse and is not breathing.
        Check                      If patient is NOT in cardiopulmonary arrest, follow orders in Sections B and C.
         One   † Attempt Resuscitation/CPR (Selecting CPR in Section A requires selecting Full Treatment in Section B)
               † Do Not Attempt Resuscitation/DNR   (Allow Natural Death)
         B     MEDICAL INTERVENTIONS:                           If patient is found with a pulse and/or is breathing.
        Check   † Full Treatment – primary goal of prolonging life by all medically effective means.
         One       In addition to treatment described in Selective Treatment and Comfort-Focused Treatment, use intubation,
                   advanced airway interventions, mechanical ventilation, and cardioversion as indicated.
                                   † Trial Period of Full Treatment.
               † Selective Treatment – goal of treating medical conditions while avoiding burdensome measures.
                   In addition to treatment described in Comfort-Focused Treatment, use medical treatment, IV antibiotics, and
                   IV fluids as indicated. Do not intubate. May use non-invasive positive airway pressure. Generally avoid
                   intensive care.
                                   † Request transfer to hospital only if comfort needs cannot be met in current location.
               † Comfort-Focused Treatment – primary goal of maximizing comfort.
                   Relieve pain and suffering with medication by any route as needed; use oxygen, suctioning, and manual
                   treatment of airway obstruction. Do not use treatments listed in Full and Selective Treatment unless consistent
                   with comfort goal. Request transfer to hospital only if comfort needs cannot be met in current location.
               Additional Orders: ___________________________________________________________________________________________________________________________

                _____________________________________________________________________________________________________________________________________________________
         C     ARTIFICIALLY ADMINISTERED NUTRITION:                    Offer food by mouth if feasible and desired.

        Check   † Long-term artificial nutrition, including feeding tubes.   Additional Orders: ________________________
         One    † Trial period of artificial nutrition, including feeding tubes.  __________________________________________
                † No artificial means of nutrition, including feeding tubes.   __________________________________________
         D     INFORMATION AND SIGNATURES:

               Discussed with:       † Patient  (Patient Has Capacity)  † Legally Recognized Decisionmaker
                † Advance Directive dated _______, available and reviewed Æ  Health Care Agent if named in Advance Directive:
                † Advance Directive not available                    Name: ________________________________________
                † No Advance Directive                               Phone:   _______________________________________
               Signature of Physician / Nurse Practitioner / Physician Assistant (Physician/NP/PA)
               My signature below indicates to the best of my knowledge that these orders are consistent with the patient’s medical condition and preferences.
               Print Physician/NP/PA Name:                    Physician/NP/PA Phone #:  Physician/PA License #, NP Cert. #:

               Physician/NP/PA Signature: (required)                                   Date:
               Signature of Patient or Legally Recognized Decisionmaker
               I am aware that this form is voluntary. By signing this form, the legally recognized decisionmaker acknowledges that this request regarding
               resuscitative measures is consistent with the known desires of, and with the best interest of, the individual who is the subject of the form.
               Print Name:                                                         Relationship: (write self if patient)

               Signature: (required)                       Date:                      Your POLST may be added to a
                                                                                       secure electronic registry to be
               Mailing Address (street/city/state/zip):    Phone Number:             accessible by health providers, as
                                                                                           permitted by HIPAA.
                 SEND FORM WITH PATIENT WHENEVER TRANSFERRED OR DISCHARGED
        * Form versions with effective dates of 1/1/2009, 4/1/2011,10/1/2014 or 01/01/2016 are also valid
                                                                                                                    121
   119   120   121   122   123   124   125   126   127   128   129