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Hawaii Do Not Resuscitate Form


Hawaii Do Not Resuscitate Form
Hawaii Do Not Resuscitate Form
HIPAA PERMITS DISCLOSURE OF POLST TO OTHER HEALTH CARE PROFESSIONALS AS NECESSARY
Physician Orders for Life-Sustaining Treatment (POLST)
First follow these orders, then contact
physician. This is a Physician Order Sheet
based on the person‟s current medical condition
and wishes. Any section not completed implies
full treatment for that section. Everyone shall be
treated with dignity and respect.
Patient „s Last Name
First /Middle Name
Date of Birth Date Form Prepared
A
Check
One
CARDIOPULMONARY RESUSCITATION (CPR): Person has no pulse and is not breathing.
Attempt Resuscitation/CPR Do Not Attempt Resuscitation/DNR (Allow Natural Death)
(Section B: Full Treatment required)
When not in cardiopulmonary arrest, follow orders in B and C.
B
Check
One
C
Check
One
ARTIFICIALLY ADMINISTERED NUTRITION: Always offer food and liquid by mouth if feasible
(See Directions on next page for information on nutrition & hydration) and desired.
No artificial nutrition by tube. Defined trial period of artificial nutrition by tube.
Goal:________________________________
Long-term artificial nutrition by tube.
Additional Orders:__________________________________________________________________
D
SIGNATURES AND SUMMARY OF MEDICAL CONDITION:
Discussed with:
Patient Patient‟s Surrogate (Health Care Decision-maker) Parent of Minor Guardian
Signature of Physician
My signature below indicates to the best of my knowledge that these orders are consistent with the person‟s medical condition
and preferences.
Print Physician Name
Physician Phone Number
Date
Physician Signature (required)
Physician License #
Signature of Patient, Surrogate, Parent of Minor or Guardian
By signing this form, the legally recognized decision maker acknowledges that this request regarding resuscitative measures
is consistent with the known desires of, and in the best interests of, the individual who is the subject of the form.
Signature (required)
Name (print)
Relationship (write self if patient)
Summary of Medical Condition
Office Use Only
SEND FORM WITH PERSON WHENEVER TRANSFERRED OR DISCHARGED
Hawaii Do Not Resuscitate Form
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