Maine POLST Form - Free Download
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HIPAA PERMITS DISCLOSURE TO HEALTH CARE PROFESSIONALS AS NECESSARY FOR TREATMENT 4/2009
Physician Orders for Life-Sustaining Treatment (POLST) Maine
First follow these orders, then contact physician,
NP or PA. These medical orders are based on the
patient’s current medical condition and
preferences. Any section not completed does not
invalidate the form and implies full treatment for
Last Name / First / Middle Initial
City / State / Zip:
Date of Birth:
Gender: M F
CARDIOPULMONARY RESUSCITATION (CPR): Patient has no pulse and is not breathing.
__Attempt Resuscitation/CPR __ Do Not Attempt Resuscitation/DNR (Allow Natural Death)
When not in cardiopulmonary arrest, follow orders in B, C and D.
MEDICAL INTERVENTIONS: Patient has pulse and/or is breathing
__Comfort Measures Only: Use medication by any route, positioning, wound care and other measures to
relieve pain and suffering. Use oxygen, suction and manual treatment of airway obstruction as needed for
comfort. Do Not Transfer to Hospital for life sustaining treatment.
Transfer if comfort needs cannot be met in current setting.
__Limited Additional Interventions: Includes all care described above. Use medical treatment and
monitoring as indicated. Do not use intubation, advanced airway interventions, or mechanical ventilation.
May consider less invasive airway support (e.g. CPAP, BiPAP). Transfer to hospital if indicated. Avoid
__Full Treatment: Includes all care described above. Use intubation, advanced airway interventions,
mechanical ventilation, and cardioversion as indicated. Transfer to hospital if indicated. Includes
__No antibiotics. Use other measures to relieve symptoms.
__Determine use or limitation of antibiotics when infection occurs.
__Use antibiotics if medically indicated.
ARTIFICIALLY ADMINISTERED NUTRITION / HYDRATION: Offer food / liquids by mouth if feasible.
Part 1 – Nutrition:
__No artificial nutrition by tube
__Trial period of artificial nutrition by tube.
__Long-term artificial nutrition by tube.
Part 2 – Hydration:
__No artificially administered fluids
__Trial period of artificial hydration.
__Full treatment with artificially administered fluids.
BASIS FOR ORDERS
My signature below indicates to the best of my knowledge that these orders are consistent with the patient’s
current medical condition and preferences as indicated by:
Basis for determining patient’s preferences (check all that apply)
__Advance Directive (on file)
__Patient’s current statement to Physician /NP/ PA
__Patient’s statement to authorized representative
__ Best interest determined by authorized representative (no
advance directive / preferences unknown)
Discussion with: (check all that apply)
__Parent of a minor
__ Health Care Agent
Print Name of Primary Care Professional Phone:
Print Name of Signing Physician / PA/ NP Phone:
Signature of Physician / PA /NP (required) Date: