Pennsylvania POLST Form - Free Download
4.5, 3228 votes
Please vote for this template if it helps you.
Pennsylvania POLST Form
Pennsylvania POLST Form
SEND FORM WITH PERSON WHENEVER TRANSFERRED OR DISCHARGED
To follow these orders, an EMS provider must have an order from his/her medical command physician
Pennsylvania
Orders for Life-Sustaining
Treatment (POLST)
Last Name
First/Middle Initial
Date of Birth
FIRST follow these orders, THEN contact physician, certified registered nurse practitioner or physician assistant. This is an Order Sheet based on the
person’s medical condition and wishes at the time the orders were issued. Everyone shall be treated with dignity and respect.
A
Check
One
CARDIOPULMONARY RESUSCITATION (CPR): Person has no pulse and is not breathing.
CPR/Attempt Resuscitation DNR/Do Not Attempt Resuscitation (Allow Natural Death)
When not in cardiopulmonary arrest, follow orders in B, C and D.
B
Check
One
MEDICAL INTERVENTIONS: Person 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, oral 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
location.
LIMITED ADDITIONAL INTERVENTIONS Includes care described above. Use medical treatment, IV fluids and
cardiac monitor as indicated. Do not use intubation, advanced airway interventions, or mechanical ventilation.
Transfer to hospital if indicated. Avoid intensive care if possible.
FULL TREATMENT Includes 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:
D
Check
One
No antibiotics. Use other measures to relieve
symptoms.
No hydration and artificial nutrition by tube.
Determine use or limitation of antibiotics when
infection occurs, with comfort as goal
Trial period of artificial hydration and nutrition by tube.
Use antibiotics if life can be prolonged
Long-term artificial hydration and nutrition by tube.
Additional Orders
E
Check
One
SUMMARY OF GOALS, MEDICAL CONDITION AND SIGNATURES:
Discussed with
Patient
Parent of Minor
Health Care Agent
Health Care Representative
Court-Appointed Guardian
Other:
Patient Goals/Medical Condition:
By signing this form, I acknowledge that this request regarding resuscitative measures is consistent with the known
desires of, and in the best interest of, the individual who is the subject of the form.
Physician /PA/CRNP Printed Name:
Physician /PA/CRNP Phone Number
Physician/PA/CRNP Signature (Required):
DATE
Signature of Patient or Surrogate
Signature (required)
Name (print)
Relationship (write “self” if patient)
PaDOH version 10-14-10
1 of 2
Pennsylvania POLST Form Previous Page Pennsylvania POLST Form Next Page
Pennsylvania POLST Form
Previous

1/2

Next