To save space, these faqs will use the shorter name polst. To find your states advance directive form, use our resource statebystate advance directive forms. The polst form at a minimum must include the patient name, resuscitation orders section a and signature of a physician, physician assistant or certified registered nurse practitioner section e. The appointed surrogate decision maker can then sign the polst form on behalf of their loved one. Sustaining treatment is a form printed on bright pink paper that makes a persons wishes for endoflife care known to. Nevada polst forms may be ordered by clicking here. The programs ultimate goal is to carefully elicit, accurately record and reliably honor patient preferences to have or to limit medical treatments across all settings of care. However, we also recognize the members right to determine his or her own care. Physician orders for lifesustaining treatment polst. If no new form is completed, full treatment and resuscitation may be provided. Polst physicians orders for lifesustaining treatment. Page 1 of 4 frequently asked questions this document refers to the illinois department of public health uniform donotresuscitate advance directivephysician orders for lifesustaining treatment form.
A polst form represents and summarizes a patients wishes in. The original polst form, on bright green paper, stays with you at all times. Polst forms may be obtained online from the pennsylvania department of. Artificially administered nutritionfluids ndicated. An attending physician who issues an order using the polst form and who transfers the patient to another physician shall inform the. A polst physicians orders for life sustaining treatment is basically a more detailed and specific dnr do not resuscitate orders. Like a do not resuscitate dnr order, the form tells emergency medical personnel and other health care providers whether or not to administer cardiopulmonary resuscitation cpr in the event of. Modifying and voiding polst a person with capacity can, at any time, void the polst form or change hisher mind about hisher treatment preferences by executing a verbal or written advance directive or a new polst form. The georgia polst collaborative currently consists of over 40 statewide organizations. Form 4 sample polst form page 1 each state that provides for physician orders for lifesustaining treatment polst has its own form and its own name for the form polst, molst, post, or most.
Upon arrival at or admission to a hospital or other facility, the polst. Provider orders for life sustaining treatment polst. Pennsylvaniapennsylvania orders for lifesustaining treatment. Wyopolst providers orders for life sustaining treatment. A polst form may be appropriate for anyone with a serious andor lifelimiting disease. The patient or legal representative signs the form to indicate the voluntary nature of the form and that the contents of the form are consistent with the patients desires and values. Free download washington polst form pdf, 156kb and customize with our editable templates, waivers and forms for your needs.
If orders change complete a new polst and write void across this polst. Print persons name last, first, middle date of birth print persons address contact information print surrogate health care decision maker address phone number directions for health care professional completing polst g must be completed by a physician or advance practice nurse. This section is applicable in situations where the person has decision making capacity when the polst form is completed. In some states it is called by a different name such as post, molst, most, etc. According to the national polst paradigm program, the polst form was originally introduced as a means to reinforce a patients own ad by making endoflife wishes known as a binding medical order. National form information for professionals patient guides learn more. Polst stands for physicians orders for lifesustaining treatment. Additional information regarding polst and other endoflife resources is on the washington state medical associations website. A polst form is generally only appropriate for people who are in the final year of life, or suffering from an advanced stage terminal illness or an illness from which they are not expected to recover. National polst form guide for professionals pdf, 38 pages. Pennsylvania orders for lifesustaining treatment polst. Polst is the providers orders for lifesustaining treatment polst program in montana. Polst provider orders for lifesustaining treatment is an approach to improving endoflife care in the united states, encouraging providers to speak with patients and create specific medical orders to be honored by health care workers during a medical crisis.
Oregon was the first to roll out the program in 1991, followed by five other states including pennsylvania where i live. Wishes committee and was designed to be consistent with pennsylvania law. The physician orders for life sustaining treatment polst form is a physician order form that communicates medical information about a patients end of life care wishes. This is accomplished by the development of an effective communication process to assure patient wishes are communicated to. The polst form shall remain effective unless revoked by the attending physician upon the consent of the patient or the patients authorized person. Additional copies of the wyopolst form can be obtained by contacting the wyoming department of health, aging division, community living. The molstpostpolst form is goldenrodcolored in ohio and pink in indiana and. Send a copy of the voided form to the polst registry required. It is designed to improve the quality of care people receive at the end of life. Most 74% of the respondents agreed that the polst program provides clear instructions about patients preferences and 91% agreed that the polst program is useful in determining which treatments to provide when. Georgia became the 16th state to have a polst program endorsed by the national polst paradigm. Not in all states as of this time, but more states are accepting this form. For permission to use the ed form contact the ohsu center for ethics in. Requirements and information for printing oregon polst.
Polst information for providers on that webpage you find the pdf of hawaiis official polst form that you can download and print download this consumer guide to polst as a pdf file 2sided, 1. The polst form is usually for persons with serious illness or frailty. This excellent short video nicely summarizes the essentials of polst. Please document their forms in your medical records. Physician orders for life sustaining treatment polst. In pennsylvania, a physician assistant signature requires a. A surrogate may only void or modify an existing polst form, or execute a new one, if named in this section by the person. Original form should be printed on yellow cardstock, and orignal form should accompany patient. A polst form is a legal document for people with an advanced progressive or terminal illnesses and specifies the type of care a person would like in an emergency medical situation. Polst began in oregon in 1991 and currently exists at some level in 42 states and meets the national polst standard in 18 states.
The polst is generally a one page, twosided uniquely identifiable form. Copy of the polst form both sides for the medical record andor scan into the medical record place appropriate hospital information label on the copy of the polst form in the upper right corner of the polst and write copy on the form and the date copied. Physician orders for lifesustaining treatment wikipedia. Free washington polst form pdf 156kb 2 pages page 2.
The patient is transferred from one care setting or care level to another, o r thei saub n lc g p, or the. We have provided a sample form based on the post form from the state of west virginia as an example. Oregon has served as the founding polst program since the early 1990s, creating what is now called oregon polst. Physician order for lifesustaining treatment polst is a form developed by the georgia department of public health pursuant to official code of georgia section 3114.
Photocopies and faxes on any color of paper also are legal and valid forms. Whats a polst physicians orders for life sustaining. Physicians orders for life sustaining treatment polst. Department of health advance directive practitioner. Provider orders for lifesustaining treatment polst aft. A health care professional can complete the polst form based on family members understanding of their loved ones wishes. Provider orders for life sustaining treatment polst plays an integral role in advance care planning to improve the quality of care for patients who are seriously ill by creating a voluntary process that identifies, documents, communicates and honors patient medical treatment wishes through shareddecision making and portable medical orders. When completed, the polst form is a physician order, treated as such. Although polst forms are currently available in pennsylvania, these forms presently are not recognized by pennsylvania law.
Advance directives or physician orders for lifesustaining. We understand a facility, physician or mental health provider may conscientiously object to an advance directive. Doing it better is a new free polst video 7 min 22 sec available from the national polst office. Video is pending updates to the polst form 11717 ordering polst forms. Pennsylvania orders for lifesustaining treatment as defined under. A polst form is a doctors order that helps you keep control over medical care at the end of life. A polst form requires a signature from an md, do, pa, or np to be valid and should only be filled out and signed after an indepth conversation between the patient and health care provider about the patients goals of care the oregon polst form is updated every two to three years. California polst education program april 2011 coalition for compassionate care of california materials made possible by a grant from the california healthcare. The polst form is portable, following the patient through all care settings, including home, emergency rooms, hospitals, and nursing homes. The polst form specifies the types of medical treatment that a patient wishes to receive towards the end of life.
Photocopies and faxes of signed wyopolst forms are legal and valid. In 1991, physicians in oregon developed the physician orders for lifesustaining treatment polst program to address a specific and substantive problem. Record all treatments entered on this polst as orders in patients chart. The national physician orders for life sustaining treatment polst paradigm.
Place the current original polst form under the doctors order section of. The problems with physician orders for lifesustaining. Free download pennsylvania polst form pdf, 98kb and customize with our editable templates, waivers and forms for your needs. A physician order for lifesustaining treatment, better known as polst 1, is a tool for translating a patients goals and preferences for treatment into a medical order. Introduction to the polst form pennsylvania orders for life sustaining treatment polst is a medical order that gives patients more control over their endoflife care. If included in an electronic medical record, follow voiding procedures of facilitycommunity. Small clarifications were made to the document by dph on april 27, 2016 and this is the form used today.
Pennsylvania orders for lifesustaining treatment polst raven. In 45% of cases where a polst was present, emts reported that it changed treatment. Revoking polst if the polst becomes invalid or is replaced by an updated version, draw a line through sections a through e of the invalid polst, write void in large letters across the form, and sign and date the form. Because the polst is a medical order, only health care facilities or health care providers are able to order polst forms. To void polst, draw a line through sections a through d and write void in large letters. Completing the polst form no patient is required to complete a polst form.
503 215 661 1440 317 82 1056 336 290 517 1414 1047 313 472 1488 1552 314 1563 127 1431 919 1292 504 1224 90 358 1173 1106 186 462 635 1390 705 1073 582 27 27 550 101 641 1048 934 572 1141 855 649 12