The Provider Orders for Life-Sustaining Treatment (POLST) form in Hawaii is a medical document designed to communicate a patient's preferences regarding life-sustaining treatments. This form reflects the individual's current medical condition and wishes, ensuring that healthcare providers follow the specified orders. It is essential for patients and their families to complete the POLST form accurately to guide medical decisions in critical situations.
Fill out the POLST form by clicking the button below.
The Hawaii Provider Orders for Life-Sustaining Treatment (POLST) form plays a crucial role in ensuring that patients receive medical care that aligns with their personal wishes and current health conditions. This form facilitates communication between patients, their families, and healthcare providers, allowing for clear directives on life-sustaining treatments. It covers various aspects of care, including cardiopulmonary resuscitation (CPR) preferences, medical interventions, and the administration of nutrition. Patients can indicate their choices, such as whether they wish to receive full treatment, limited interventions, or comfort measures only. The form also addresses the administration of artificially provided nutrition and hydration, allowing individuals to specify their preferences. Importantly, the POLST form must be signed by a licensed physician or advanced practice registered nurse in Hawaii, ensuring that the orders are medically appropriate. Each section left incomplete defaults to full treatment, emphasizing the need for thorough discussions between patients and their healthcare providers. Regular reviews of the POLST form are recommended, especially when there are significant changes in health status or treatment preferences. This ensures that the document remains relevant and reflective of the patient's wishes.
HIPAA PERMITS DISCLOSURE OF POLST TO OTHER HEALTH CARE PROFESSIONALS AS NECESSARY
PROVIDER ORDERS FOR LIFE-SUSTAINING TREATMENT (POLST) - HAWAI‘I
FIRST follow these orders. THEN contact the
Paient’s Last Name
paient’s provider. This Provider Order form is
based on the person’s current medical condiion
First/Middle Name
and wishes. Any secion not completed implies
full treatment for that secion. Everyone shall be
Date of Birth
Date Form Prepared
treated with dignity and respect.
A
CARDIOPULMONARY RESUSCITATION (CPR): ** Person has no pulse and is not breathing **
Atempt Resuscitaion/CPR
Do Not Atempt Resuscitaion/DNAR (Allow Natural Death)
Check
(Secion B: Full Treatment required)
One
If the paient has a pulse, then follow orders in B and C.
B
MEDICAL INTERVENTIONS:
** Person has pulse and/or is breathing **
Comfort Measures Only Use medicaion by any route, posiioning, wound care and other measures to relieve pain
and suffering. Use oxygen, sucion and manual treatment of airway obstrucion as needed for comfort. TRANSFER IF COMFORT
needs cannot be met in current locaion.
Limited Addiional Intervenions Includes care described above. Use medical treatment, anibioics, and IV fluids as indicated. Do not intubate. May use less invasive airway support (e.g. coninuous or bi-level posiive airway pressure). TRANSFER to hospital if indicated. Avoid intensive care.
Full Treatment Includes care described above. Use intubaion, advanced airway intervenions, mechanical venilaion, and defibrillaion/cardioversion as indicated. TRANSFER to hospital if indicated. Includes intensive care.
Addiional Orders:
C
ARTIFICIALLY ADMINISTERED NUTRITION: Always offer food and liquid by mouth if feasible
(See Direcions on next page for informaion on nutriion & hydraion)
and desired.
No arificial nutriion by tube.
Defined trial period of arificial nutriion by tube.
Long-term arificial nutriion by tube.
Goal:
D
SIGNATURES AND SUMMARY OF MEDICAL CONDITION - Discussed with:
Paient or
Legally Authorized Representaive (LAR). If LAR is checked, you must check one of the boxes below:
Guardian
Agent designated in Power of Atorney for Healthcare
Paient-designated surrogate
Surrogate selected by consensus of interested persons (Sign secion E)
Parent of a Minor
Signature of Provider (Physician/APRN licensed in the state of Hawai‘i.)
My signature below indicates to the best of my knowledge that these orders are consistent with the person’s medical condiion and preferences.
Print Provider Name
Provider Phone Number
Date
Provider Signature (required)
Provider License #
Signature of Paient or Legally Authorized Representaive
My signature below indicates that these orders/resuscitaive measures are consistent with my wishes or (if signed by LAR) the known wishes and/or in the best interests of the paient who is the subject of this form.
Signature (required)
Name (print)
Relaionship (write ‘self’ if paient)
Summary of Medical Condiion
Official Use Only
SEND FORM WITH PERSON WHENEVER TRANSFERRED OR DISCHARGED
Paient Name (last, first, middle)
Gender
M F
Patient’s Preferred Emergency Contact or Legally Authorized Representative
Name
Address
Phone Number
Health Care Professional Preparing Form
Preparer Title
E
SURROGATE SELECTED BY CONSENSUS OF INTERESTED PERSONS
(Legally Authorized Representaive as outlined in secion D)
I make this declaraion under the penalty of false swearing to establish my authority to act as the legally authorized represen-
taive for the paient named on this form. The paient has been determined by the primary physician to lack decisional
capacity and no health care agent or court appointed guardian or paient-designated surrogate has been appointed or the agent or guardian or designated surrogate is not reasonably available. The primary physician or the physician’s designee has made reasonable efforts to locate as many interested persons as pracicable and has informed such persons of the paient's lack of capacity and that a surrogate decision-maker should be selected for the paient. As a result I have been selected to act as the paient’s surrogate decision-maker in accordance with Hawai‘i Revised Statutes §327E-5. I have read secion C below and understand the limitaions regarding decisions to withhold or to withdraw arificial hydraion and nutriion.
Relaionship
Compleing POLST
DIRECTIONS FOR HEALTH CARE PROFESSIONAL
•Must be completed by health care professional based on paient preferences and medical indicaions.
•POLST must be signed by a Physician or Advanced Pracice Registered Nurse (APRN) licensed in the state of Hawai‘i and the paient or the paient’s legally authorized representaive to be valid. Verbal orders by providers are not acceptable.
•Use of original form is strongly encouraged. Photocopies and FAXes of signed POLST forms are legal and valid.
Using POLST
• Any incomplete secion of POLST implies full treatment for that secion. Secion A:
• No defibrillator (including automated external defibrillators) should be used on a person who has chosen “Do Not Atempt Resuscitaion.”
Secion B:
•When comfort cannot be achieved in the current seing, the person, including someone with “Comfort Measures Only,” should be transferred to a seing able to provide comfort (e.g., treatment of a hip fracture).
•IV medicaion to enhance comfort may be appropriate for a person who has chosen “Comfort Measures Only.”
•A person who desires IV fluids should indicate “Limited Intervenions” or “Full Treatment.”
Secion C:
• A paient or a legally authorized representaive may make decisions regarding arficial nutriion or hydraion. However, a surrogate who has not been designated by the paient (surrogate selected by consensus of interested persons) may only make a decision to withhold or withdraw arificial nutriion and hydraion when the primary physician and a second independent physician cerify in the paient’s medical records that the provision or coninuaion of arificial nutriion or hydraion is merely prolonging the act of dying and the paient is highly unlikely to have any neurological response in the future. HRS §327E-5.
Reviewing POLST
It is recommended that POLST be reviewed periodically. Review is recommended when:
•The person is transferred from one care seing or care level to another, or
•There is a substanial change in the person’s health status, or
•The person’s treatment preferences change.
Modifying and Voiding POLST
•A person with capacity or, if lacking capacity the legally authorized representaive, can request a different treatment plan and may revoke the POLST at any ime and in any manner that communicates an intenion as to this change.
•To void or modify a POLST form, draw a line through Secions A through E and write “VOID” in large leters on the original and all copies. Sign and date this line. Complete a new POLST form indicaing the modificaions.
•The paient’s provider may medically evaluate the paient and recommend new orders based on the paient’s current health status and goals of care.
Kōkua Mau – Hawai‘i Hospice and Palliaive Care Organizaion
Kōkua Mau is the lead agency for implementaion of POLST in Hawai‘i. Visit www.kokuamau.org/polst to download a copy
or find more POLST informaion. This form has been adopted by the Department of Health July 2014
Kōkua Mau • PO Box 62155 • Honolulu HI 96839 • info@kokuamau.org • www.kokuamau.org
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