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Montana POLST Form

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Montana POLST Form
Montana POLST Form
HIPAA PERMITS DISCLOSURE OF POLST TO OTHER HEALTH CARE PROVIDERS AS NECESSARY
Montana Provider Orders For Life-Sustaining Treatment (POLST)
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.
Patient’s Last Name:
Patient’s First Name:
Date of Birth:
Male Female
Section
A
Select only
one box
Treatment Options:
If patient does not have a pulse and is not breathing:
Resuscitate (CPR) Do Not Resuscitate (DNR/No CPR)
(Allow Natural Death)
If patient is not in cardiopulmonary arrest, follow orders found in sections B and C
Section
B
Select only
one box
Treatment Options:
If patient has a pulse and/or is breathing:
Comfort Measures: Treat patient with dignity and respect. Keep patient clean, warm and dry. Reasonable
measures are to be made to offer food and fluids by mouth. Use medication, positioning, wound care and other
measures to relieve pain and discomfort. Use oxygen, suction and manual treatment of airway obstruction as
needed for comfort. DO NOT transfer to hospital for life-sustaining treatment. Transfer ONLY if comfort
needs cannot be met in current location.
Limited Additional Interventions: In addition to the care described above, use medical treatment, IV fluids and
cardiac monitoring as indicated. Do not use intubation, advanced airway interventions or mechanical interventions.
May consider use of less invasive airway support such as CPAP or BiPAP. Transfer to hospital if indicated.
Avoid
Intensive Care.
Full Treatment: In addition to the care described above, use intubation, advanced airway interventions,
mechanical ventilation and cardioversion as indicated. Transfer to hospital if indicated. Include
Intensive Care.
Other Instructions: ____________________________________________________________________________
_____________________________________________________________________________________________
Section
C
Select only
one box
Antibiotics:
No antibiotics except if needed for comfort (i.e. urinary tract infection)
No Invasive (IM/IV) antibiotics
Aggressive treatment Other instructions: __________________________________________
Section
D
Select only
one box
Medically Administered Nutrition:
No Feeding tube
Feeding tube for defined trial period
Feeding tube long-term Other Instructions: ___________________________________________
Section
E
Discussed with: Patient/Resident Healthcare Agent/Surrogate Court appointed Guardian
Other _________________
Name of Agent/Surrogate/Guardian/Other: _____________________________________________
Phone #: ____________________________
The basis for these orders is: Patient’s preference Patient’s best interest
Other ___________________________
Signature of Physician/NP/PA (mandatory)
Physician/NP/PA Name (type or print)
Time and Date
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 POLST Form
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