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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.
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
If patient is not in cardiopulmonary arrest, follow orders found in section B and C
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
Artificial Fluids and Nutrition:
Feeding tube NoFeeding tube
IV fluid NoIV fluid
Antibiotics and Blood Products:
Blood Products No Blood Products
Advance Directives: The following documents also exist:
Living Will Other_________________________________________________
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