Maine POLST Form - Free Download
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Maine POLST Form
Maine POLST Form
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
that section.
Last Name / First / Middle Initial
Address:
City / State / Zip:
Date of Birth:
Gender: M F
A
Check
One
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.
B
Check
One
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
intensive care.
__Full Treatment: Includes all care described above. Use intubation, advanced airway interventions,
mechanical ventilation, and cardioversion as indicated. Transfer to hospital if indicated. Includes
intensive care.
Additional Orders:
C
Check
One
ANTIBIOTICS
__No antibiotics. Use other measures to relieve symptoms.
__Determine use or limitation of antibiotics when infection occurs.
__Use antibiotics if medically indicated.
Additional Orders:
D
Check
One
for
part 1
And
One
for
part 2
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.
Goal:_________________________
__Long-term artificial nutrition by tube.
Part 2 Hydration:
__No artificially administered fluids
__Trial period of artificial hydration.
Goal:__________________________________
__Full treatment with artificially administered fluids.
Additional Orders:
E
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)
Print Name of Primary Care Professional Phone:
Print Name of Signing Physician / PA/ NP Phone:
Signature of Physician / PA /NP (required) Date:
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