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Florida POLST Form

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Florida POLST Form
Florida POLST Form
SEND FORM WITH PATIENT WHENEVER TRANSFERRED OR DISCHARGED
Date
Use of original form is strongly encouraged. Photocopies and facsimiles of completed POLST forms are legal and valid.
HIPAA PERMITS DISCLOSURE TO HEALTH CARE PROFESSIONALS AS NECESSARY FOR TREATMENT
Physician Orders for Life-Sustaining Treatment (POLST)-Florida
Follow these orders until orders change.
These medical orders are based on the
patient’s current medical condition and
preferences. Any section not completed
does not invalidate the form and implies
full treatment for that section. With
significant change of condition new
orders may need to be written.
Patient Last Name
Patient First Name
Middle Int.
Gender
M . F
Last 4 SSN:
Address: (street/ city/ state/ zip)
A
Check
One
CARDIOPULMONARY RESUSCITATION(CPR): Patient has no pulse and/or is not breathing
Attempt Resuscitation/CPR
Do Not Attempt Resuscitation/DNR
When not in cardiopulmonary arrest, follow orders in B and C.
B
Check
One
MEDICAL INTERVENTIONS: If patient has pulse and is breathing.
Comfort Measures Only (Allow Natural Death) Relieve pain and suffering through the use of any medication by any route,
positioning, wound care and other measures. Use oxygen, suction and manual treatment of airway obstruction as needed
for comfort. Patient prefers no transfer to hospital for life-sustaining treatments. Transfer if comfort needs cannot
be met in current location. Consider hospice referral if appropriate.
Treatment Plan: Maximize comfort through symptom management.
Limited Additional Interventions In addition to care described in Comfort Measures Only, use medical treatment,
antibiotics, IV fluids and cardiac monitor as indicated. No intubation, advanced airway interventions, or mechanical
ventilation. May consider less invasive airway support (e.g. CPAP, BiPAP). Transfer to hospital if indicated. Generally
avoid the intensive care unit.
Treatment Plan: Provide basic medical treatments.
Full Treatment In addition to care described in Comfort Measures Only and Limited Additional Interventions, use intubation,
advanced airway interventions, and mechanical ventilation as indicated. Transfer to hospital and /or intensive care unit if
indicated.
Treatment Plan: Full treatment including life support measures in the intensive care unit.
Additional Orders:
C
ARTIFICIALLY ADMINISTERED NUTRITION: Offer food by mouth if feasible.
Check
One
No artificial nutrition by tube. Additional Orders:_____________________________
Defined trial period of artificial nutrition by tube. ____________________________________________
Long-term artificial nutrition by tube. ____________________________________________
D
Check
One
HOSPICE or PALLIATIVE CARE (complete if applicable) - consider referral as appropriate
Patient/Resident Currently enrolled
in Hospice Care
Contact:________________________
Patient/Resident Currently enrolled
in Palliative Care
Contact:________________________
Not indicated or refused
E
Basis for The Orders is: (Check all that apply)
Life Limiting Advanced Illness
Advanced Frailty Patient’s preferences
SIGNATURES
Print Physician Name
MD/DO License #
Phone Number
Physician Signature (mandatory)
Date
Print Patient/Resident or Surrogate/Proxy Name
Relationship (write ‘self’ if patient)
Patient or Surrogate Signature (mandatory)
Date
Florida POLST Form
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