POLST ORDERS

Physician Orders For Life-Sustaining Treatment (POLST) are also know as a Living Will or Medical Directive.  The POLST allows the individual to determine to what extent that person wants life sustaining medical treatment following a severe accident or terminal disease.  It is highly recommended for American senior citizens to complete and file with your medical provider. It really serves a two-fold purpose; 1) The individual makes his/her own choice about end of life and 2) removes the burden of choosing the options regarding sustaining life or allow to pass naturally and comfortably.

Montana and HIPPA permit disclosure of the POLST to health care providers as needed.  Another requirement is the document must be signed and verified by physician, physician assistant (PA) or APRN to be valid. Finally, each section must be filled out or the medical care personnel will assume to provide all life sustaining measures.

The Montana POLST form is easy to fill-out and left with the provider. It begins with general information; name, birthdate and gender.

SECTION A TREATMENT OPTIONS: if patient is not breathing and has no pulse.

(Select One Only)

____ Attempt CPR           ____ DO NOT Resuscitation (CPR)

SECTION B TREATMENT OPTIONS: if patient has a pulse and is breathing

(Select one Only)

_____ Comfort Measures Only:  pain medication by any route, positioning, wound care, oxygen, suction and manual treatment for airway obstruction(s), may use CPAP or BiPAP

_____ Limited Additional Measures: in addition to comfort add IV fluids and cardiac monitoring 

DO NOT intubate, use advanced airway interventions or mechanical interventions

_____  Full Treatment

in addition to both above treatments add intubation, advanced airway interventions, mechanical ventilation and cardiovascular as needed

SECTION C ATRIFICIALLY ADMINISTERED NUTRITION

(Select One Only)

_____ No Artificial Nutrition by Tube

_____ Defined Trial Period of Artificial Nutrition, Specifically (how long) ___________________

_____ Long Term Artificial Nutrition by Tube

SECTION D: DISCUSSED WITH

(Check all that apply)

_____ patient        _____ Health-Care Agent       _____ Court Appointed Guardian

_____ other _________________________________

Finish by filling out the bottom: your name, phone, date prepared, 

Followed by signature of Physician, or PA,  or APRN