AWPHD Publications & Resources - End of Life Care Manual

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	TOC \| Intro \| 1 \| 2 \| 3 \| 4 \| 5 \| 6
	Intro \| A
	i \| ii \| iii \| iv

Download PDF Sample Form

Physician Orders for Life-Sustaining Treatment (POLST) This is a Physician Order Sheet. Based on patient/resident wishes and medical indications, it summarizes any Advance Directive. Any section not completed indicates full treatment for that section. When need for resuscitation occurs, first follow these orders, then contact physician. The purpose of Parts B, C, and D are to provide physician orders on end of life care as patients move through the various health care settings. Notify physician of any significant change in medical condition.	Last Name of Patient/Resident
	First Name/Middle Initial of Patient/Resident
	Patient/Redsident Date of Birth

Physician Orders for Life-Sustaining Treatment

Part A
check
one box
only

Resuscitation. Patient/resident has no pulse and is not breathing.
For all other medical circumstances, refer to "Section B, Medical Interventions."

Resuscitate Do Not Resuscitate (DNR)

Part B check one box only	Medical Interventions. Includes Emergency Medical Services. Patient/resident has pulse and/or is breathing. Comfort Measures Only. Oral and body hygiene, reasonable efforts to offer food and fluids orally. Medication, positioning, wound care, warmth, appropriate lighting and other measures to relieve pain and suffering. Privacy and respect for the dignity and humanity of the patient/resident. Transfer only if comfort measures fail. Limited Interventions. All care above and consider oxygen, suction, treatment of airway obstruction (manual only). Advanced Interventions. All care above and consider oral/nasal airway, bag-mask/demand valve, monitor cardiac rhythm, medication, IV fluids. Full Treatment/Resuscitation. All care above plus CPR, intubation and defibrillation. Other Instructions:
Part C check one box only	Antibiotics (notify physician of new infection) No antibiotics except if needed for comfort No invasive (IM/IV) antibiotics Full Treatment Other Instructions:
Part D check one box only	Artificially Administered Fluids and Nutrition. Oral fluids and nutrition must be offered if medically feasible. No feeding tube/IV fluids (provide other measures to assure comfort) No long term feeding tube/IV fluids (provide other measures to assure comfort) Full Treatment Other Instructions:
Part E check one box only	Discussed with: Patient/Resident Agent of Burable Power of Attorney Court-appointed Guardian Spouse Other (specify)	The Basis for These Orders Is: (circle all that apply) Patient's request Patient's best intrest Patient's know preference Medical futility

Physician Name (print) Physician Signature (mandatory)

Phone Date

Patient/Resident or Legal Surrogate for Health Care Signature (mandatory)

Date

Part F

Patient/Resident Preferences as a Guide for this POLST From.

Significant thought has been given to life-sustaining treatment and patient preferences have been communicated to physician and/or health care provider(s). This document reflects patient treatment preferences. Further information regarding these preferences may be obtained from the following:

Advance Directive (Attach copy)
Court-Appointed Guardian (Attach copy of documentation)
Name of Guardian
Agent for Durable Power of Attorney for Health Care (Attach copy)
Name of Agent

Please review these orders if there is a substantial change in my health status such as:

Close to death	Improved Condition	Advanced progressive illness
Extraordinary suffering	Permanent unconsciousness

Signature of Person Preparing Form

Preparer Name (print)

Date

How to Change This Form

This POLST Form should be reviewed periodically and if:

The patient/resident is transferred from one care setting or care level to another, or
There is substantial change in patient/resident health status, or
The patient/resident treatment preference change.

First, review “Patient/Resident Preferences as a guide for this POLST Form” (Part F).
Second, record the review in “Review of this POLST Form.” (Part G).
Finally, if this form is to be voided, draw a line through the “Physician Orders”
and/or write the word “VOID” in large letters, then sign or initial the form.
After voiding the form, a new form may be completed.

If no new form is completed, full treatment and resuscitation may be provided.

Part G	Review of this POLST Form
	Review Date	Reviewer	Location of Review	Review Outcome
				No Change Form Voided New form completed
				No Change Form Voided New form completed
				No Change Form Voided New form completed
				No Change Form Voided New form completed
				No Change Form Voided New form completed

Patient/Resident or Legal Surrogate for Health Care Signature (mandatory)

Date

Original From Must Accompany Patient/Resident When Transferred or Discharged

Washington State Department of Health

Association of Washington Public Hospital Districts

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