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HIPAA PERMITS DISCLOSURE OF POLST TO OTHER HEALTH CARE PROVIDERS AS NECESSARY
Montana ProviderOrders For Life-Sustaining Treatment (POLST)
THIS FORM MUST BE SIGNED BY A PHYSICIAN, PAor 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’sLast Name:
Patient’sFirst Name:
Date of Birth:
MaleFemale
Section
A
Select only
one box
Treatment Options:
If patient does not have a pulse andis 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 useintubation, advanced airway interventionsor mechanical interventions.
May consider use of less invasive airway support such as CPAP or BiPAP. Transfer to hospitalif indicated.
Avoid
Intensive Care.
Full Treatment: In addition to the care described above, use intubation, advanced airway interventions,
mechanical ventilationand cardioversion as indicated. Transfer to hospital if indicated. Include
Intensive Care.
Other Instructions:____________________________________________________________________________