Minnesota POLST Form - Free Download | Page 2
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tHese orders refleCt tHe patient’s treatment wisHes
Relationship to Patient Phone Number
summary of goals
signature of patient or HealtH Care agent / guardian / surrogate
Minnesota POLST — October, 2011
HealtH Care agent:
parent(s) of minor
HealtH Care direCtive/
tHe basis for tHese orders is patient’s
(check all that apply):
• Must be completed by a health care professional based on patient
preferences and medical indications.
• If the goal is to support quality of life in last phases of life,
then DNR must be selected in Section A.
• If the goal is to maintain function and quality of life, then
either CPR or DNR may be selected in Section A.
• If the goal is to live as long as possible, then CPR must be
designated in Section A.
• POLST must be signed by a physician, nurse practitioner, Doctor
of Osteopathy, or Physician Assistant (when delegated). * e
signature of the patient or heath care agent / guardian/ surrogate
is strongly encouraged.
• Any section of POLST not completed implies most aggressive
treatment for that section.
• An automatic external debrillator (AED) should not be used for
a patient who has chosen “Do Not Attempt Resuscitation.”
• Oral uids and nutrition must always be oered if medically
• When comfort cannot be achieved in the current setting, the pa-
tient, including someone with “Comfort Measures Only,” should
be transferred to a setting able to provide comfort.
• An IV medication to enhance comfort may be appropriate for a
patient who has chosen “Comfort Measures Only”.
• Articially-administered hydration is a measure which may pro-
long life or create complications. Careful consideration should be
made when considering this treatment option.
• A patient with capacity or the surrogate (if patient lacks capac-
ity) can revoke the POLST at any time and request alternative
• Comfort care only: At this level, provide only palliative measures
to enhance comfort, minimize pain, relieve distress, avoid invasive
and perhaps futile medical procedures, all while preserving the
patients’ dignity and wishes during their last moments of life.
is patient must be designated DNAR status in section A for
this choice to be applicable in section B.
• Limit Interventions and Treat Reversible Conditions: e goal
at this level is to provide limited additional interventions aimed at
the treatment of new and reversible illness or injury or manage-
ment of non life-threatening chronic conditions. Treatments may
be tried and discontinued if not eective.
• Provide Life-Sustaining Care: e goal at this level is to pre-
serve life by providing all available medical care and advanced life
support measures when reasonable and indicated. For patient’s
designated DNR status in section A above, medical care should
be discontinued at the point of cardio and respiratory arrest.
is POLST should be reviewed periodically and a new POLST
completed if necessary when:
1. e patient is transferred from one care setting or level
to another, or
2. ere is a substantial change in the patient’s health
3. A new POLST should be completed when the patient’s treat-
ment preferences change.
direCtions for HealtH Care professionals
faxed Copies and pHotoCopies of tHis form are valid.
to void tHis form, draw a line aCross seCtions a - d and write “void” in large letters.
Name of Health Care Professional Preparing Form Preparer Title Phone Number Date Prepared