Healthcare POLST Template

PHYSICIAN ORDERS FOR LIFE-SUSTAINING TREATMENT (POLST)

These Physician Orders for Life-Sustaining Treatment (POLST) are medical orders that document current treatment preferences for a patient with a serious illness or frailty. They are intended to be honored by health care professionals across care settings. Completion of this form is based on discussion between the patient or legally authorized representative and the clinician. The patient may revoke or amend orders at any time by communicating preferences to treating clinicians. Please complete all applicable sections.

Patient Information

Patient Name:    Date of Birth:

Address:

Clinical Information

Section A — Cardiopulmonary Resuscitation (CPR)

Select one option. These are medical orders to be followed by emergency and inpatient personnel.

Attempt cardiopulmonary resuscitation (CPR) — Provide CPR, defibrillation, advanced airway and resuscitative medications as indicated.

Do Not Attempt Resuscitation (DNR) / Do Not Resuscitate — No chest compressions, defibrillation, intubation, or advanced resuscitative measures.

Section B — Medical Interventions

Select one medical intervention level appropriate to clinical situation and patient preferences.

Full treatment — Aggressive medical treatment including intubation and mechanical ventilation as indicated. Transfer to hospital and ICU when necessary.

Selective/limited treatment — Hospital transfer if needed; treat reversible conditions; avoid intubation unless specifically requested.

Comfort-focused treatment — Emphasize relief of pain and suffering; avoid hospital transfer and intensive life-prolonging measures.

Section C — Antibiotics

Antibiotic preferences during a life-threatening infection.

Do not use antibiotics except for comfort measures only.

Use antibiotics when medically indicated, including IV antibiotics.

Case-by-case decision — Consider benefits and burdens; decide with clinician input.

Section D — Artificially Administered Nutrition

Preferences regarding feeding by tube when patient cannot eat by mouth.

No artificial nutrition by tube.

Trial period of tube feeding — reassess after trial.

Long-term artificial nutrition desired.

Advance Directives and Privacy Acknowledgment

I have an advance directive or living will that supplements these orders.

Patient or authorized representative acknowledges receipt of privacy practices and consents to disclosure of orders to other health care providers as necessary to implement these orders.

Clinician Attestation (Required)

The clinician attests that these orders reflect the patient's current treatment preferences after discussion and clinical assessment. The clinician has explained the nature and expected outcomes of treatment options and has documented any inconsistencies between these orders and any existing advance directives.

Legal Certification and Patient Consent

By signing below, I confirm that I understand these orders and that they reflect my current treatment preferences or those of the patient for whom I am authorized to act. I understand that these orders are medical orders to be followed by clinicians and emergency personnel, and that I may revoke or change these orders at any time. I understand that the clinician signing above has discussed treatment options and likely outcomes with me or my authorized representative.

Signature of patient or authorized representative acknowledges informed consent for these orders and attests to the representative's authority to make health care decisions on behalf of the patient where applicable.

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