Missouri Transportable Physician Orders For Patient Preferences (TPOPP) Form - Free Download
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Missouri Transportable Physician Orders For Patient Preferences (TPOPP) Form
Missouri Transportable Physician Orders For Patient Preferences (TPOPP) Form
FORM SHALL ACCOMPANY PERSON WHEN TRANSFERRED OR DISCHARGED
Kansas – Missouri Transportable Physician Orders for Patient Preferences (TPOPP)
This Physician Order set is based on the patient’s current medical condition and preferences. Any section
not completed indicates full treatment for that section. Photocopy or fax copy of this form is valid.
Last Name:
First Name: Middle Initial:
Date of Birth: Last 4 SSN:
Gender:
M F
A.
CHECK
ONE
B.
CHECK
ONE
C.
CHECK
ONE
D.
CHECK
ALL
THAT
APPLY
CARDIOPULMONARY RESUSCITATION (CPR): Person has no pulse and is not breathing.
If patient is not in cardiopulmonary arrest, follow orders in B and C.
Attempt Resuscitation/CPR
(Selecting CPR in Section A requires selecting Full Treatment in Section B)
Do Not Attempt Resuscitation (DNAR/no CPR/Allow Natural Death)
MEDICAL INTERVENTIONS: Person has pulse and/or is breathing.
Additional Orders:
MEDICALLY ADMINISTERED NUTRITION: Offer food by mouth if feasible and desired.
No medically administered nutrition, including feeding tubes.
Medically administered nutrition, including feeding tubes, for trial period:
Long term medically administered nutrition, including feeding tubes
INFORMATION AND SIGNATURES
Discussed with:
Patient/Resident Agent/DPOA healthcare Parent of minor Legal guardian
Signature of patient or recognized decision maker
By signing this form, the recognized decision maker acknowledges that this request regarding above treatment measures is consistent with the
known desires, and with the best interest, of the individual who is the subject of the form.
Print name: Signature (required):
Phone:
Relationship (write “self” if patient):
Address:
Signature of physician
My signature below indicates to the best of my knowledge that these orders are consistent with the person’s medical condition and preferences.
Print physician name:
Date:
Physician phone:
Physician signature
(required):
Additional Orders:
Health care surrogate Other (specify):
HIPAA PERMITS DISCLOSURE TO HEALTH CARE PROFESSIONALS AND PROXY DECISION MAKERS AS NECESSARY FOR TREATMENT
© Center For Practical Bioethics, 1111 Main, Suite 500 (Harzfeld Building), Kansas City, MO 64105 | 816-221-1100
September 2012
Practitioners: Go to www.practicalbioethics.org
for TPOPP resources
- For Educational Purposes Only -
Comfort Measures Only.
Treat with dignity and respect. Keep clean, warm, and dry. 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. Transfer to hospital
only if comfort needs cannot be met in current location.
TREATMENT GOAL: ATTEMPT TO MAXIMIZE COMFORT THROUGH SYMPTOM MANAGEMENT ONLY.
Limited Additional Interventions.
In addition to care described in Comfort Measures Only, use medical treatment, antibiotics, and IV fluids as indicated. Do not intubate.
May use non-invasive positive airway pressure. Generally avoid intensive care. Transfer to hospital only if treatment needs cannot be met
in current location.
TREATMENT GOAL: ATTEMPT TO RESTORE FUNCTION WITH TREATMENTS FOR REVERSIBLE CONDITIONS.
Full Treatment.
In addition to care described in Comfort Measures Only and Limited Additional Interventions, use intubation, advanced airway interventions,
mechanical ventilation, and defibrillation/cardioversion as indicated. Transfer to hospital if indicated. Includes intensive care.
TREATMENT GOAL: ATTEMPT TO PROLONG LIFE BY ALL MEDICALLY EFFECTIVE MEANS.
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