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Washington Physician Orders For Life Sustaining Treatment (POLST)

The Washington Physician Orders for Life Sustaining Treatment (POLST) is provided by Washington State Department of Health.

Washington Physician Orders For Life Sustaining Treatment (POLST)
Washington Physician Orders For Life Sustaining Treatment (POLST)
Physician Orders for Life-Sustaining Treatment
A
FIRST follow these orders, THEN contact physician, nurse practitioner
or PA-C. The POLST is a set of medical orders intended to guide
emergency medical treatment for persons with advanced life limiting
illness based on their current medical condition and goals. Any section
not completed implies full treatment for that section. Everyone shall
be treated with dignity and respect.
Medical Conditions/Patient Goals:
Cardiopulmonary resusCitation (Cpr): Person has no pulse and is not breathing.
mediCal interventions: Person has pulse and/or is breathing.

Use medication by any route, positioning, wound care and other measures
to relieve pain and suffering. Use oxygen, oral suction and manual treatment of airway obstruction as
needed for comfort.
Patient prefers no hospital transfer: EMS contact medical control to deter-
mine if transport indicated to provide adequate comfort.
CPR/Attempt Resuscitation
DNAR/Do Not Attempt Resuscitation (Allow Natural Death)
Choosing DNAR will include appropriate comfort measures and may still include the range of
treatments below. When not in cardiopulmonary arrest, go to part B.
 Includes care described above. Use medical treatment, IV fluids and
cardiac monitor as indicated. Do not use intubation or mechanical ventilation. May use less invasive air-
way support (e.g. CPAP, BiPAP).
Transfer to hospital if indicated. Avoid intensive care if possible.
 Includes care described above. Use intubation, advanced airway interventions, mechanical
ventilation, and cardioversion as indicated.
Transfer to hospital if indicated. Includes intensive care.
Additional Orders: (e.g. dialysis, etc.) _________________________________________________________
Check
One
HIPAA PERMITS DISCLOSURE OF POLST TO OTHER HEALTH CARE PROVIDERS AS NECESSARY
B
Check
One
Photocopies and FAXes of signed POLST forms are legal and valid. May make copies for records
SEND ORIGINAL FORM WITH PERSON WHENEVER TRANSFERRED OR DISCHARGED
Last Name - First Name - Middle Initial
Date of Birth
Gender
M F
Last 4 #SSN
signatures: The signatures below verify that these orders are consistent with the patient’s medical
C
condition, known preferences and best known information. If signed by a surrogate, the
patient must be decisionally incapacitated and the person signing is the legal surrogate.
Discussed with:
Patient Parent of Minor
Legal Guardian Health Care Agent
Spouse/Other:
PRINT — Physician/ARNP/PA-C Name
Physician/ARNP/PA-C Signature (mandatory)
Patient or Legal Surrogate Signature (mandatory)
PRINT — Patient or Legal Surrogate Name
Phone Number
Agency Info/Sticker
Date
Phone Number
Date
Person has:
Health Care Directive (living will)
Durable Power of Attorney for Health Care
Living Will Registry
Encourage all advance care planning
documents to accompany POLST
Revised 2/2011
(DPOAHC)
OVER
p
Washington Physician Orders For Life Sustaining Treatment (POLST)
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