Form Ioci 17-564 - Idph Uniform Practitioner Order For Life-Sustaining Treatment (Polst) Form

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HIPAA PERMITS DISCLOSURE OF POLST TO HEALTH CARE PROFESSIONALS AS NECESSARY FOR TREATMENT

■

IDPH UNIFORM PRACTITIONER ORDER FOR

LIFE-SUSTAINING TREATMENT (POLST) FORM

State of Illinois

Illinois Department of Public Health

Patient Last Name

Patient First Name

For patients, use of this form is completely voluntary.

Follow these orders until changed. These medical orders are

based on the patient’s medical condition and preferences.

Date of Birth (mm/dd/yy)

Gender

Any section not completed does not invalidate the form and

implies initiating all treatment for that section. With significant

Address (street/city/state/ZIPcode)

change of condition new orders may need to be written.

CARDIOPULMONARY RESUSCITATION

(CPR)

If patient has no pulse and is not breathing.

Attempt Resuscitation/CPR

Do Not Attempt Resuscitation/DNR

Check

(Selecting CPR means Full Treatment in Section B is selected)

One

When not in cardiopulmonary arrest, follow orders B and C.

MEDICAL INTERVENTIONS

If patient is found with a pulse and/or is breathing.

Full Treatment: Primary goal of sustaining life by medically indicated means. In addition to treatment de-

Check

scribed in Selective Treatment and Comfort-Focused Treatment, use intubation, mechanical ventilation and

One

cardioversion as indicated. Transfer to hospital and/or intensive care unit if indicated.

(optional)

Selective Treatment: Primary goal of treating medical conditions with selected medical measures.

In addition to treatment described in Comfort-Focused Treatment, use medical treatment, IV fluids and IV

medications (may include antibiotics and vasopressors), as medically appropriate and consistent with patient

preference. Do Not Intubate. May consider less invasive airway support (e.g. CPAP, BiPAP). Transfer to hos-

pital, if indicated. Generally avoid the intensive care unit.

Comfort-Focused Treatment: Primary goal of maximizing comfort. Relieve pain and suffering through the

use of medication by any route as needed; use oxygen, suctioning and manual treatment of airway obstruction.

Do not use treatments listed in Full and Selective Treatment unless consistent with comfort goal. Request

transfer to hospital only if comfort needs cannot be met in current location.

Optional Additional Orders

________________________________________________________________________

MEDICALLY ADMINISTERED NUTRITION

(if medically indicated) Offer food by mouth, if feasible and as desired.

q Long-term medically administered nutrition, including feeding tubes.

Additional Instructions (e.g., length of trial period)

Check

q Trial period of medically administered nutrition, including feeding tubes. __________________________________________

One

(optional)

q No medically administered means of nutrition, including feeding tubes. __________________________________________

DOCUMENTATION OF DISCUSSION

(Check all appropriate boxes below)

Patient

Agent under health care power of attorney

Parent of minor

Health care surrogate decision maker (See Page 2 for priority list)

Signature of Patient or Legal Representative

Signature (required)

Name (print)

Date

_______________________________________________

________________________________

____________

Signature of Witness to Consent

(Witness required for a valid form)

I am 18 years of age or older and acknowledge the above person has had an opportunity to read this form and have witnessed the

giving of consent by the above person or the above person has acknowledged his/her signature or mark on this form in my presence.

Signature (required)

Name (print)

Date

_______________________________________________

________________________________

____________

Signature of Authorized Practitioner

(physician, licensed resident (second year or higher), advanced practice nurse or physician assistant)

My signature below indicates to the best of my knowledge and belief that these orders are consistent with the patient’s medical condition and preferences.

Print Authorized Practitioner Name (required)

Phone

__________________________________________________

(

) _________ - ______________

Authorized Practitioner Signature (required)

Date (required)

Page 1

__________________________________________________

______________________

(Prior form versions are also valid.)

Form Revision Date - May 2017