Fill and Sign the Colorado Medical Orders for Scope of Treatment Most Form

Colorado A dvan ce Dire ctiv es C onso rti um , P O Bo x 27 02 02 , L ittle ton, CO 801 27v .7 .1 0SEND FORM WITH PERSON W HENEV ER TRANS FERRED OR DISCHARGED L ast N ameF ir st N ame /M id d le N ameD ate o f B ir thSe xC ol orado Medi cal O rdersfor Scope of T re atment (MOST )• FIRST foll ow th ese o rde rs, T HEN co n ta ct P hysic ia n, A dv anc ed Pra ctic eNur se (AP N), or P hysic ia n As sis ta nt ( PA) , for fur the r o rd er s if indic ate d.• T hese M ed ic al Or ders are b ase d on th e p ers o n’s m ed ic al co nd iti on & w is h es.• An y se c tio n no t co m ple ted im plie s fu ll treatm en t fo r th at se c tio n.• M ay only be c om ple ted by, o r o n beh alf of, a pers o n 18 yea rs of ag e o r o ld er.• E very o ne s hall be tr ea te d w it h di gni ty a nd re sp ect.H air C olo rEy e C olo rR ac e/E th nic ity A Ch eckOn e Box Only CARD IO PU LM ONAR Y R ESUS CITA TIO N (C PR ) Person h as n o p ulse and is n ot b reat hin g. No CPR Do Not Resusc it a te /DNR /Al low Natur al De ath Ye s CP R At te m pt Resusc it a ti on/ CPR W he n no t i n C ardi opu lm onar y ar re st, f ollo w or ders B , C , and DB Check On e Box Only M ED IC A L I NTER VEN TIO NS Person h as pu lse and/or is b reat hin g. Co mfor t M easu res O nly: Use m edi cation by any rout e, p osit ioni ng, and othe r m easur es t o re lie v e pain and su ffe ring . U se oxy gen, s ucti on and m anua l tr e atm ent of air w ay obs tr uc tion a s ne ede d fo r com for t. D o not t r an sfe r to ho spi ta l fo r l i f e -s us ta ini ng tr e atm ent .Trans fe r onl y if com for t ne ed s c annot be met in c urre n t lo catio n; EM S-C ont ac t m edi cal con tr o l. L im it e d Ad dit ion al In te rve ntion s: Inc lude s care de sc ribe d a bov e. U se m edi cal tr e a tm ent , I V flu ids and card ia c m oni tor a s i ndi cate d . D o no t us e in tuba tion, adv anc ed air w ay int erv ent ions , or mec ha nic al ve nt il a tion. Tran sfe r t o hos pital if ind ic a te d . Av oid i nte n siv e c ar e; E M S-Cont act m edi cal con tr ol .Full T reat me nt: Inc lude s c a re de sc ribe d abov e. U se in tuba tion, a dvanc ed a ir w ay int erv ent ions , mec ha nical vent il a tio n, a nd card iov ers ion as indi ca te d.Tr ans fe r t o hos pita l if in di cat ed. I nclu des in te n siv e c a re . E MS-Cont act m edi cal con tr ol .Addi ti ona l O rd ers: (E M S= Em erg enc y M ed ic a l Se rv ic e s) C Ch eckOn e Box Only ANTIB IO TIC S N o a ntibi otic s. U se ot he r m easur es to re lie v e sy m pt om s. Us e ant ib iot ic s w he n c om for t is the goa l. U se ant ib iot ic s. Addi ti ona l O rd ers: D Check On e Box Only ARTIF IC IA LL Y A DM IN IST ER ED N UTR IT IO N A ND H YDRATIO N****A lw ay s of fe r foo d & wat er by m out h if fe a sib le ***** N o a rti f ic ia l nut rit ion/ hydr ati on by tube . (N O TE: Spe cia l ru le s for prox y by sta tut e on page 2)Patie nt has exe cut ed a “Li ving Wil l” P atie nt has not exe cut ed a “ L iv ing Will ” D efin ed t ria l period o f arti f ic ia l nut rit io n/ hy dration by tube . (Le ngth o f tr ia l: Goal: ) Long-te rm arti f ic ia l nut rit ion /hy dratio n by tube . Addi ti ona l O rd ers: D IS CUS SED WITH :Patie ntA gent und er M ed ic al D ur ab le Pow er o f A ttor neyP roxy ( pe r s ta tut e C .R .S. 15- 18.5-103( 6))Guard ia nO the r: E Che ck A ll That Apply (S EC TIO N R ESE R VE D FO R FUTU RE USE )S UM MARY O F M EDI CAL CONDIT IO N(S) :Physic ian/AP N /PA Sig natu re (m an dato ry )Co lora d o Li ce n se #:P rin t P hysic ian/AP N/P A Na me, Ad dre ss a n d Phon e Nu mberDa teHIPAA PERMITS DISCLOSURE OF THIS INFO RMATION TO OTHER HEALTH CARE PROFESSIONALS AS NECESSARY Colorado A dvan ce Dire ctiv es C onso rti um , P O Bo x 27 02 02 , L ittle ton, CO 801 27v .7 .1 0SEND FORM WITH PERSON W HENEV ER TRANS FERRED OR DISCHARGED SI GNATU RE O F PATIE N T, A GEN T, GU AR D IA N , O R P RO XY B Y ST ATU TE ( MAN D ATO RY )Si gni fic a n t th ou ght has be en g iv en t o the desir e d s cope of e nd- of-lif e tr e a tm ent an d t hese ins tr uc ti ons . Pre fe re nc es ha vebe en d is c us se d a nd exp re ss e d t o a he alt h c are pro fe ss iona l. T his doc ument re fle cts tho se tr e a tm ent pre fe re nc es, w hichm ay als o be doc um ent ed in a M DPO A, C PR D ir e c ti v e, Li ving Will , o r ot he r adv anc e dir e c ti v e (a tta c he d if av aila bl e). To the ext ent tha t m y pr ior adv anc e d ir e c ti v es do n ot c onf li c t w ith th ese M ed ic a l O rd ers fo r Sc ope o f T re at men t, m y pr iora dv anc e dir e c ti v es s ha ll re m ain i n f ull for ce a nd e ffe c t.( I f sign ed by su rroga te , pr efe re nc es e xp re ss e d m ust re fle c t pat ie n t’ s w is h es as best un derstood by s u rr og ate.)Sig na tu reNa me (P rin t)Rela tion sh ip / S urro gate sta tu s(write “ se lf” if pa tie nt)Da te Sig ned (Revokes all p re vio us M OS T forms)P rima ry Conta ct P erso n fo r th e P atie ntR ela tion sh ip and /o r M DP OA , P ro xyP hon e Nu mb er/ Conta ct In fo rm ati onHe alth Care Pro fessi ona l P re pari ng FormP re pa re r TitleP hon e Nu mb erDa te Pre pare dHo spice Pro gra m (if a pp lic ab le )Add re ssPhon e Nu mb erDa te Enro lledD IRE CT IO NS FO R H EAL TH CARE PROFESS IONA LS C OM PLETING TH ESE M EDICAL O RDERS• Must b e c om ple ted by a h ea lt h care p ro fe ssio nal base d on patie nt pre fe re n ce s an d m ed ic a l in dic a ti on s. • T hese Me dic al Or ders m ust be s ig ned by a p hysic ia n, a dvan ced pra c ti ce n urs e , o r p hysic ia n ass is ta nt to b e vali d. Physic ia n Assis ta nts mu st in clu de p hysic ia n name and co nta ct in fo rma tion.• V erb al ord ers are a ccep ta ble with fo llo w-u p sig natu re b y physic ia n or a dvan ce d pra c tic e n urs e in acco rd an ce w ith fa c ili ty po lic y. • O rig in al fo rm str ongly en co ura g ed . P ho to co py, f ax , a nd ele ctr o nic i mag e o f s ig ned MOS T f orm s are le gal a n d vali d. U SING THES E M EDICAL O RDERS• Any se c ti on of th ese M ed ic al Or ders no t co m ple ted im plie s fu ll tr e a tm en t fo r t hat se c tio n. • A s e m i- a u to matic exte rn al defib rilla tor ( AED) s ho uld no t be u se d on a p ers o n who has ch o se n “Do Not A ttem pt R esu sc it a tio n.” • C om fo rt care is nev er o ptio nal; Or al flu ids an d nutr iti on m ust a lw ay s be o ffe re d if m ed ic all y fe a sib le . • W hen co m fo rt can no t be a ch ie ved in th e c urre n t se tti ng, th e pers o n, in clu d in g so m eo ne w it h “C om fo rt M ea su re s O nly ,” s h o uld b e tran sfe rre d to a s ettin g ab le to pro vid e c om fo rt (e .g ., p innin g of a h ip f r a ctu re ). • A p ers o n who ch o ose s “C om fo rt M ea su re s On ly ” o r “Lim it e d Add itio nal I n te rv en tio ns,” s ho u ld n o t b e e nte re d in to a t ra u m a syste m . EMS sh ould co nta ct Me dic al C ontr ol fo r fu rth er ord ers o r dir e c tio n re g ard in g transfe rs. • IV med ic ati on to e nhan ce c om fo rt m ay be a ppro pria te f or a p ers o n who has ch o se n “C om fo rt M ea su re s O nly .” • T re atm en t of deh yd ra tio n is a m ea su re th at m ay pro lo ng life . A p ers o n who desir es IV f lu id s sh o uld in dic a te “ L im ite d In te rv en tio ns” o r “Full Treatment.” • If a h ea lt h care p ro vid er c onsid ers th ese o rd ers m ed ic all y in ap pro p ria te , h e o r s he m ay dis c u ss co ncern s w ith th e p atie nt o r auth oriz ed su rro gate a nd re v is e o rd ers w ith co nse n t of p atie nt or s urro gate . • If a h ea lt h care p ro vid er o r facili ty ca n no t co m ply with th e o rd ers due to p olic y or p ers o nal eth ics, t he p ro vid er o r f ac ilit y m ust arra n ge f o r tr an sfe r to th e p ati en t to a no th er p ro vid er o r fac il it y an d pro vid e a ppro pria te c are in th e m ean ti m e. • P rox y by s ta tut e is a d ecis ion m aker se le cte d t hroug h a pr oxy pr ocess acco rd in g to C .R .S. 1 5-1 8.5 -1 03(6 ), w ho ma y not d ec li ne a rtif icial nutr itio n/h yd ra tio n (A N H) with out an atte nd in g ph ysic ia n an d a s eco n d physic ia n train ed in neu ro lo gy certif yin g th at pro vis io n of ANH would mere ly pro lo ng th e ac t of d yin g an d is u nli k ely to re su lt i n th e r esto ra tio n of t h e patie nt to ind ep en d en t neu ro lo gic al fu ncti onin g. R EVI EW ING TH ESE M EDIC AL ORDERSThese Me dic al Or ders s h o uld be r ev ie wed re g ula rly an d when th e p ers o n is tran sfe rre d fr o m one c are s etti ng or c are le vel toan o th er, th ere i s a s ub sta ntia l ch an ge i n th e p ers o n’s hea lt h sta tu s, t he p ers o n’s tr e a tm en t pre fe re n ce s ch an ge, o r w hen co nta c t i nfo rm atio n ch an g es.RE VIE W OF T H IS M OST FO RMRevie w Da teRe vie w erL oca tio n of Re vie wRe vie w Out co m e No C han ge F orm V oid ed Ne w Form C omplete d No C han ge F orm Void ed Ne w Form Comple te d No C han ge F orm Void ed Ne w Form Comple te d No C han ge F orm Void ed Ne w Form Comple te d HIPAA PERMITS DISCLOSURE OF THIS INFO RMATION TO OTHER HEALTH CARE PROFESSIONALS AS NECESSARY Colorado A dvan ce Dire ctiv es C onso rti um , P O Bo x 27 02 02 , L ittle ton, CO 801 27v .7 .1 0