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Montana Do Not Resuscitate Form


Montana Do Not Resuscitate Form
Montana Do Not Resuscitate Form
HIPAA PERMITS DISCLOSURE OF POLST TO OTHER HEALTH CARE PROVIDERS AS NECESSARY
Montana Provider Orders For Life-Sustaining Treatment (POLST)
Patient’s Last Name:
Patient’s First Name:
Date of Birth:
THIS FORM MUST BE SIGNED BY A PHYSICIAN, PA or APRN IN SECTION E TO BE VALID
If any section is NOT COMPLETE:
Provide the most treatment included in that section
EMS: If questions/concerns, contact Medical Control.
Male Female
Section
A
Select only
one box
Cardiopulmonary Resuscitation: If patient does not have a pulse and/or is not breathing:
Resuscitate (Full Code) Do Not Resuscitate (No Code)
(Allow Natural Death)(Comfort One)
Patient does not want any heroic or
Life-saving measures.
If patient is not in cardiopulmonary arrest, follow orders found in section B and C
Section
B
Select only
one box
Medical Interventions: If patient has a pulse and/or is breathing:
Comfort Measures: Please treat patient with dignity and respect. Reasonable measures are to be made to
offer food and fluids by mouth and attention must be paid to hygiene. Medication, positioning, wound care, and
other measures shall be used to relieve pain and discomfort. Use oxygen, suction and manual treatment of airway
obstruction as needed for comfort. EMS:
Patient prefers no transfer to hospital for life-sustaining treatment.
Transfer if comfort needs cannot be met in current location.
Limited Additional Interventions: In addition to the care described above, cardiac monitoring and oral/IV
medications may be provided. EMS: Transfer to hospital if indicated, do not perform intubation or advanced airway
interventions. Hospital: Do not admit to Intensive Care.
Full Treatment: In addition to the care described above, endotracheal intubation, advanced airway interventions,
mechanical ventilation, defibrillation and cardioversion may be provided. Hospital: Admit to Intensive Care if
indicated.
Other Instructions:
Section
C
May select
more than
one
Artificial Fluids and Nutrition:
Feeding tube No Feeding tube
IV fluid No IV fluid
Other Instructions:
Antibiotics and Blood Products:
Antibiotics No Antibiotics
Blood Products No Blood Products
Other Instructions:
Section
D
Advance Directives: The following documents also exist:
Living Will Other _________________________________________________
_________________________________________________________________________
Section
E
Patient or Surrogate Signature: ________________________________ Date:_____________
(by signing the POLST, I agree that this POLST supersedes my living will, if the two conflict)
Print Patient or Surrogate (person with authority under 50-9-106, MCA)
Name:________________________________ Relationship:___________________
Physician/APRN/PA (in consultation with supervising physician) Signature: ________________ Date:_______
Print Physician/APRN/PA Name : ______________________________ MT License Number: _________________
Contact Phone Number: _________________ Discussed with:
Patient Spouse Other __________
The basis for these orders is:
Patient’s request Patient’s known preference ____________________
FORM SHALL ACCOMPANY PATIENT WHENEVER TRANSFERRED OR DISCHARGED
Use of original form is strongly encouraged. Photocopy, fax or electronic copies of signed POLST forms are legal and valid
Montana Do Not Resuscitate Form
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