Physician orders for lifesustaining treatment polst is a. Polst physician orders for life sustaining treatment. Health care professionals can download a blank polst form from this website to print. Polst physician orders for lifesustaining treatment. Providers and patientssurrogates need to be aware that if they choose not to sign an oregon polst, it may be harder for the ems or physicians in washington to honor it. Using polst any incomplete section of polst implies full treatment for that section. Photocopies of polst forms on white paper are valid. With over 55,000 polst forms received in 2015, the registry has now collected and maintained these orders for over 200,000 oregonians. The program is based on effective communication of patient wishes, documentation of medical orders and a promise by a health care professional to honor these wishes. The patient is transferred from one care setting or care level to another, o r thei saub n lc g p, or the. Oregon has served as the founding polst program since the early 1990s, creating what is now called oregon polst.
The registry allows health care professionals treating a patient access to their polst orders if the paper polst form cannot be found. 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. First follow these orders, then contact physicianaprnpa. Most 74% of the respondents agreed that the polst program provides clear instructions about patients preferences and 91% agreed that the polst program is.
Oregon polst program the oregon portable orders for lifesustaining treatment polst program is designed to improve the quality of care people receive at the end of life. Free washington do not resuscitate dnr order form pdf. Changing, modifying or revising a polst form requires completion of a new polst form. However, an english version of the polst form must be completed and signed so that emergency medical personnel and healthcare providers can follow the orders. This cover sheet should be attached to polst forms distributed at skilled nursing facilities snf. Additional information regarding polst and other endoflife resources is on the washington state medical associations website. A polst physicians orders for life sustaining treatment is basically a more detailed and specific dnr do not resuscitate orders. Sustaining treatment polst form has been in use since about 1995.
Requirements and information for printing oregon polst. Requirements and information for printing oregon polst forms. Free download oregon polst form pdf, 224kb and customize with our editable templates, waivers and forms for your needs. Electronic endoflife and physician orders for life. Physician orders for lifesustaining treatment wikipedia.
Physician orders for lifesustaining treatment polst form. The polst form helps to ensure that medical providers will understand your wishes at a glance, but it is not a substitute for a thorough and properly prepared health care directive. The polst form t he polst form serves to translate the individuals treatment goals into a set of portable medical orders that must be honored in all settings. The patient should retain the original on terra green colored paper. We have provided a sample form based on the post form from the state of west virginia as an example. Registry to electronically submit polst form pdfs andor electronic polst form data.
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. This excellent short video nicely summarizes the essentials of polst. Use of original form is strongly encouraged, however photocopies and faxes of signed polst forms are legal and valid. Please check back periodically to make sure that you are using. The oregon polst form remains a protected document and in order to print the form certain guidelines must be followed.
The polst form can be changed or voided at any time. Collect all polst forms ready for submission to the regsitry. Information on the oregon poist program is available online at. 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. 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. Whats a polst physicians orders for life sustaining. Physicians orders for lifesustaining treatment polst. Facilities may not require residents to have a polst form, but it is highly recommended. Doing it better is a new free polst video 7 min 22 sec available from the national polst office. Physicians orders for life sustaining treatment 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.
The polst form, initially designed to decrease unnecessary health care interventions at the end of life, is being promoted as a tool for decreasing healthcare costs and has several limitations. These medical orders are based on the patients current medical condition and preferences. When you enter a hospital, hospice, or other health care facility, a member of the staff may. The polst must be completed by a medical provider mddopaaprn based on patient preferences and medical indications. Today the polst form is used in oregon, washington, west virginia. Center for ethics in health care, oregon health science university ohsu. Photocopies and faxs of signed polst forms are legal and valid.
Photocopies and faxes on any color of paper also are legal and valid forms. It was first developed by a task force of health professionals at the oregon health sciences university. 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. 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. Medical orders consult this form only when patient lacks decisional capacity. Previous versions of the oregon polst form remain valid. Describe what is required for the polst form to be valid. Draw line through sections a through e and write void across page if any polst form is replaced or becomes invalid. As oregons experience with the polst program grew, first responders frequently were unable to find a patients completed polst form in a time of crisis. Virtually all participants reported that their hospice used state advance directive forms to document patient wishes for lifesustaining treatments oregon, 100%.
The instructions provided below are directed towards the completion of an oregon polst form. The polst form is not a substitute for a do not resuscitate order. This is the organization that advocated for the implementation of polst in california. Wyopolst providers orders for life sustaining treatment. Although the form is to be signed by a doctor and patient, you can get to know the form and its parts at the coalition for compassionate care of californias website. To void polst, draw a line through sections a through d and write void in large letters. Physician orders for lifesustaining treatment polstflorida. A stepbystep guide to registering polst forms with the oregon polst registry. Clarify on the form any information that may be hard to read. Provider orders for lifesustaining treatment polst aft. Voiding or revoking a polst form a patient with capacity can void or revoke the form, andor request alternative treatment. In 45% of cases where a polst was present, emts reported that it changed treatment. Recognize the polst form and other valid resuscitation orders. In response to this need, the oregon polst registry was created as a publicprivate partnership with funding from private foundations to build the database and to educate the professional.
Free oregon do not resuscitate dnr order form sample. Medical decision making is often timecritical in medical emergencies. Also known as physician orders for lifesustaining treatment. Any section not completed does not invalidate the form and implies full treatment for that section. The document used for this purpose, the polst form, must be requested from the patients doctor or directly from the oregon polst program. Health care providers are authorized to print oregon polst forms.
It is up to the patient what they want their polst form to say. Additional copies of the wyopolst form can be obtained by contacting the wyoming department of health, aging division, community living section at 18004422766. End of life choices oregon provides personal support and information regarding the death with dignity act dwda and other legal end of life options to oregonians facing endoflife decisions, to the medical community and to the public. 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. The polst form is a way for the patient to say yes, i want cpr and full treatment or no, i want to stay where i am and be made comfortable, or something in the middle. The physician order for lifesustaining treatment polst is different from an advance directive. From oregon, it began to spread very gradually to other states and other parts of the country. One significant difference between the oregon and washington forms is that a patient signature is required on the washington state form, but not on the oregon form. The polst form is a portable medical order designed to support patients transitioning between facilities or who live outside a facility by communicating patient treatment wishes. Translations of the polst form are available to assist healthcare providers in explaining the form to patients and loved ones. To find your states advance directive form, use our resource statebystate advance directive forms. Additional information can be found in the oregon polst programs, guidance for oregons health care professionals. A polst form does not replace an advance directive or the requirement that residents should be offered an opportunity to complete an advance directive oar 411086004 3.
The polst is not an advance directive and does not replace it. 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. Describe how the polst form is transferred from one setting to another. Nevada polst provider order for lifesustaining treatment.