Completing POLST Form: A “How to” Guide for Physicians

Completing POLST Form: A “How to” Guide for Physicians
Ask the question: Would I be surprised if the patient is not alive or does not have decision-making capacity in one year? If the answer
is no, complete a POLST form for that individual. Document the patient’s goals of care and details of discussion upon which the orders
are based in the medical record. The POLST form reflects patient’s preferences for care based upon their current condition.
There are four patient preference sections and one signature section. The POLST form is considered complete if any of the preferences
sections and two signatures are filled in. If a preference section is not filled out, full treatment plan is assumed for that section.
Section A is designed to guide response when a person with a POLST form is in cardiopulmonary arrest. Section B, C, and D are
designed to guide care in an acute situation when the person is not in cardiopulmonary arrest.
A – Cardiopulmonary Resuscitation (CPR)
A
CODE STATUS
Check all that
apply
CARDIOPULMONARY RESUSCITATION (CPR): Patient has no pulse and is not breathing.

Attempt Resuscitation/CPR.

Allow Natural Death (AND) - Do Not Attempt Resuscitation.

Resuscitation Orders are to remain in effect during any surgical or invasive procedure.
When not in cardiopulmonary arrest, follow orders in B, C and D.
These orders apply only when the patient has no pulse and is not breathing. This section does not apply to any other medical
circumstances. For example, this section does not apply to a patient in respiratory distress because he/she is still breathing.
B – Medical Interventions
MEDICAL INTERVENTIONS: Patient has pulse and /or is breathing.
B
Check
One

Comfort Measures: Use medication by any route, positioning, wound care and other measures to relieve pain and suffering.
Use oxygen, suction and manual treatment of airway obstruction as needed for comfort. Transfer if comfort needs cannot be
met in the current location.

Limited Additional Interventions: Includes Comfort Measures and medical treatment, IV fluids and cardiac monitor as
indicated. Does not include intubation or mechanical ventilation. Avoid intensive care. Transfer to hospital if indicated.

Additional Treatment: Includes Comfort Measures, Limited Additional Interventions, lab tests, blood products, dialysis.
Transfer to hospital if indicated.

Full Treatment: Includes Additional Treatment and intubation, mechanical ventilation and cardioversion as indicated. Includes
intensive care. Transfer to hospital if indicated.

Additional Orders:
These orders apply to the patient who has a pulse and/or is breathing.
a.
Comfort Measures: i) Patient’s goals: Maximize comfort and avoid hospitalizations, ii) Treatment plan: Maximize comfort through
symptom management. Antibiotics may be used as a comfort measure. Consider a palliative care or hospice care referral or make
treatment plan for providing comfort care, e.g., pain and symptom management orders. Consider hospitalizing patient only if
comfort needs are not met otherwise. When selecting “Choose Comfort Measures” it is recommended to also select allow natural
death as well.
b. Limited Additional Interventions: i) Patient’s goals: Hospitalize if needed, but avoid mechanical ventilation and generally avoid
ICU care, ii) Treatment plan: Hospitalize if needed to treat for reversible conditions or worsening of their underlying illness with
the goal of restoring them to their current state of health, e.g., hospitalization for dehydration, pneumonia.
c. Additional Treatment: i) Patient’s goal: More aggressive care, avoid intubation and cardioversion, ii) Treatment plan would include
a. and b. and also includes lab tests, blood products, dialysis or other interventions specified by the patient.
d. Full Treatment: i) Patient goals: all life-sustaining treatments are desired, ii) Use of intubation, advanced airway intervention,
mechanical ventilation, cardioversion, transfer to hospital and use of intensive care as indicated with no limitation of treatment.
Note: Some patients with advanced illness might want all measures including intensive care treatment and temporary life support such
as mechanical ventilation but would not want to be resuscitated if these attempts fail and their heart stops. Thus a patient can request
DNR in Section A and request Full Treatment in Section B.
Additional clarifying orders to the patient’s preferences can be written under Additional Orders, e.g., “ICU treatment for sepsis but no
intubation/mechanical ventilation for respiratory failure.”
C – Antibiotics
C
Check
One
ANTIBIOTICS
No antibiotics: Use other measures to relieve symptoms.
Determine use or limitation of antibiotics when infection occurs.
Use antibiotics if life can be prolonged.
Additional Orders:
a. No Antibiotics: If the patient desires no treatment with antibiotics under any circumstances. Should the patient have a painful
infection utilize other medications to alleviate symptoms.
b. Determine use or Limitation of Antibiotics: Discuss whether to use or avoid antibiotics with patient at time of infection. This
does not preclude use of antibiotics.
c. Use antibiotics if life can be prolonged: Use antibiotics when there is an expectation the infection will be eliminated and the patient
will survive regardless of underlying condition.
Additional orders: This area can be utilized for specific orders related to the patient’s current condition. For example “treat all urinary
tract infections with po antibiotics, no IV antibiotics.”
D – Artificial Nutrition/Fluids
D
Check
One
ARTIFICIALLY ADMINISTERED NUTRITION / FLUIDS
Where indicated, always offer food or fluids by mouth if feasible.
No artificial nutrition by tube.
No IV fluids.
Defined trial period of artificial nutrition by tube.
Defined trial period of IV fluids.
Long-term artificial nutrition by tube.
Long-term IV fluids.
Additional Orders:
These orders indicate the patient’s instructions when he/she cannot take fluids by mouth. If patient can swallow, always offer food/
water by mouth. No artificial nutrition by tube is provided for a patient who prefers this treatment.
Note: No data has shown that patients with advanced progressive dementia live longer with a permanent feeding tube. Sometimes a
defined trial period of artificial nutrition by tube or IV fluids can allow time to determine the course of an illness or allow the patient
an opportunity to clarify his/her goals of care (typical times: IV fluids 2-5 days, tube feeding: approximately 30 days). If long-term artificial nutrition by tube is medically indicated and desired by the patient, then the appropriate box is checked. Placement of a feeding
tube is not a final commitment to an approach to care. It is appropriate to reconsider and remove a feeding tube as warrented.
E – Reason for Orders and Signatures
E
Check
All That
Apply
REASON FOR ORDERS AND SIGNATURES
To the best of my knowledge these orders are consistent with the patient’s current medical condition and
preferences as indicated by:
My discussion with the Patient
My discussion with the Patient’s Authorized Representative
My review of the Patient’s Advance Directive
Verbal consent was given for an “allow natural death” order.
Checks the box(es) indicating with whom the orders were discussed (patient or patient’s health care representative). The patient or
surrogate must sign the form. The physician is acknowledging that the signature below indicates that the orders are consistent with the
patient/surrogate preferences. The physician then prints his/her name, license number, and the date the orders were signed.
In the event that two physician signatures are indicated, the second physician should sign in either of the two remaining sections, crossing out the title “patient” or “patient authorized representative
Without MD Signature POLST Orders are not valid!