Physician Orders for Life-Sustaining Treatment (POLST)

First follow these orders, then contact Physician/NP/PA. A copy of the signed POLST form is a legally valid physician order. Any section not completed implies full treatment for that section.
POLST complements an Advance Directive and is not intended to replace that document.

A CARDIOPULMONARY RESUSCITATION (CPR):

If patient has no pulse and is not breathing.
If patient is NOT in cardiopulmonary arrest, follow orders in Sections B and C.

B MEDICAL INTERVENTIONS:

If patient is found with a pulse and/or is breathing.

C ARTIFICIALLY ADMINISTERED NUTRITION:

If Offer food by mouth if feasible and desired.

D INFORMATION AND SIGNATURES

Discussed with:

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.

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.

Your POLST may be added to a secure electronic registry to be accessible by health providers, as permitted by HIPAA.

Patient Information-

NP/PA’s Supervising Physician

Preparer Name-(if other than signing Physician/NP/PA)

Directions for Health Care Provider

Completing POLST

• Completing a POLST form is voluntary. California law requires that a POLST form be followed by healthcare providers, and provides immunity to those who comply in good faith. In the hospital setting, a patient will be assessed by a physician, or a nurse practitioner (NP) or a physician assistant (PA) acting under the supervision of the physician, who will issue appropriate orders that are consistent with the patient’s preferences.

• POLST does not replace the Advance Directive. When available, review the Advance Directive and POLST form to ensure consistency, and update forms appropriately to resolve any conflicts.

• POLST must be completed by a health care provider based on patient preferences and medical indications

• A legally recognized decisionmaker may include a court-appointed conservator or guardian, agent designated in an Advance Directive, orally designated surrogate, spouse, registered domestic partner, parent of a minor, closest available relative, or person whom the patient’s physician/NP/PA believes best knows what is in the patient’s best interest and will make decisions in accordance with the patient’s expressed wishes and values to the extent known.

• A legally recognized decisionmaker may execute the POLST form only if the patient lacks capacity or has designated that the decisionmaker’s authority is effective immediately.

• To be valid a POLST form must be signed by (1) a physician, or by a nurse practitioner or a physician assistant acting under the supervision of a physician and within the scope of practice authorized by law and (2) the patient or decisionmaker. Verbal orders are acceptable with follow-up signature by physician/NP/PA in accordance with facility/community policy.

• If a translated form is used with patient or decisionmaker, attach it to the signed English POLST form.

• Use of original form is strongly encouraged. Photocopies and FAXes of signed POLST forms are legal and valid. A copy should be retained in patient’s medical record, on Ultra Pink paper when possible.

Using POLST

• Any incomplete section of POLST implies full treatment for that section.

Section A:

• If found pulseless and not breathing, no defibrillator (including automated external defibrillators) or chest compressions should be used on a patient who has chosen “Do Not Attempt Resuscitation.”

Section B:

• When comfort cannot be achieved in the current setting, the patient, including someone with “Comfort-Focused Treatment,” should be transferred to a setting able to provide comfort (e.g., treatment of a hip fracture).

• Non-invasive positive airway pressure includes continuous positive airway pressure (CPAP), bi-level positive airway pressure (BiPAP), and bag valve mask (BVM) assisted respirations.

• IV antibiotics and hydration generally are not “Comfort-Focused Treatment.”

• Treatment of dehydration prolongs life. If a patient desires IV fluids, indicate “Selective Treatment” or “Full Treatment.”

• Depending on local EMS protocol, “Additional Orders” written in Section B may not be implemented by EMS personnel.

Reviewing POLST

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

• The patient is transferred from one care setting or care level to another, or

• There is a substantial change in the patient’s health status, or

• The patient’s treatment preferences change.

Modifying and Voiding POLST

• A patient with capacity can, at any time, request alternative treatment or revoke a POLST by any means that indicates intent to revoke. It is recommended that revocation be documented by drawing a line through Sections A through D, writing “VOID” in large letters, and signing and dating this line.

• A legally recognized decisionmaker may request to modify the orders, in collaboration with the physician/NP/PA, based on the known desires of the patient or, if unknown, the patient’s best interests.

This form is approved by the California Emergency Medical Services Authority in cooperation with the statewide POLST Task Force. For more information or a copy of the form, visit www.caPOLST.org.