What are the different components of a POLST Form?

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Section A: Cardiopulmonary Resuscitation (CPR)

These orders apply only when the patient has no pulse and is not breathing; this section does not apply to any other medical circumstance.  If the patient wants CPR, the box should be checked and full CPR measures should be carried out and 9-1-1 called.  If the patient does not want CPR, the box should be checked and CPR should not be performed.


Section B: Medical Interventions 

This section is designed to guide care in an acute situation when the person is not in cardiopulmonary arrest. There are three levels of medical interventions found on POLST forms:

  1. Comfort Measures Only/Allow Natural Death.  The treatment plan is to maximize comfort through symptom management.  Antibiotics may be used as a comfort measure.  This should be ordered if a patient’s goal is to maximize comfort and avoid hospitalizations unless necessary to ensure comfort needs are met.
  2. Limited Additional Interventions.  The treatment plan is to hospitalize if needed but to avoid mechanical ventilation and generally avoid ICU care.  This should be ordered if a patient’s goal is to obtain treatments for reversible conditions or exacerbations of his/her underlying disease with the goal of restoring the patient to his/her current state of health.  Examples include hospitalization for dehydration or for pneumonia.
  3. Full Treatment.  The treatment plan should include all life-sustaining treatments possible, including intubation, advanced airway intervention, mechanical ventilation, cardiodiversion, transfer to hospital and use of intensive care as indicated with no limitation of treatment. 

Section C: Artificially Administered Nutrition

These orders indicate the patient’s instructions regarding the use of artificially administered nutrition for a patient who cannot take fluids by mouth.  The POLST Program requires POLST forms to clearly state that fluids and nutrition will be provided if medically feasible.