In california, polst forms must be signed by the patient. Video is pending updates to the polst form 11717 ordering polst forms. Print persons name last, first, middle date of birth print persons address contact information print surrogate health care decision maker address phone number directions for health care professional completing polst g must be completed by a physician or advance practice nurse. This is a spanish translation of the california polst form. Because the polst is a medical order, only health care facilities or health care providers are able to order polst forms. The polst is not an advance directive and does not replace it.
Section f polst must be signed by a practitioner, meaning a physician or apn, to be valid. If no new form is completed, full treatment and resuscitation may be provided. Nevada polst forms may be ordered by clicking here. In order to maintain continuity throughout california, please follow these instructions. For example, when a patient is transferred from a nursing home to a hospital, the polst form can be left behind. Changing, modifying or revising a polst form requires completion of a new polst form. This is a repository of files intended to serve as an archive or reference for polst leaders in the development of their own materials.
A polst form is an advance care plan and can support patients towards the end of life. The coalition for compassionate care of california cccc is the home for polst in california polst physician orders for lifesustaining treatment is a medical order signed by both a patient and physician, nurse practitioner or physician assistant that specifies the types of medical treatment a patient wishes to receive toward the end of life. The polst form helps medical providers understand your wishes at a glance, but it is not a substitute for a properly prepared advance health. A polst form is generally only appropriate for people who are in the final year of life, or suffering from an advanced stage terminal illness or an illness from which they are not expected to recover. In the hospital setting, a patient will be assessed by a physician who will issue appropriate orders that are consistent with the patients preferences. The polst form deals with cardiopulmonary resuscitation cpr, and. The translated form is for educational purposes only to be used when discussing a patients wishes documented on the polst form. If you are moved between locations, your polst form will go with you. Californias polst electronic registry pilot california health care.
Under any other circumstance, medical emergency personnel are trained to. California coalition for compassionate care the coalition is the lead agency for implementation of polst in california. Physician orders for lifesustaining treatment polst form for california. This form is approved by the emergency medical services authority in cooperation with the california coalition for compassionate care and the statewide polst task force. Revoking polst if the polst becomes invalid or is replaced by an updated version, draw a line through sections a through e of the invalid polst, write void in large letters across the form, and sign and date the form. You also have the right to name someone else to make health care decisions for you. Pennsylvania orders for lifesustaining treatment polst.
Dnr and polst forms do not resuscitate dnr the prehospital do not resuscitate dnr form is an official state document developed by the california ems authority, in concert with the california medical association and emergency medical services ems providers, for the purpose of instructing ems personnel regarding a patients decision to. Any section not completed does not invalidate the form and implies full treatment for that section. Signature requirements for a valid polst form by state. Photocopies and faxs of signed polst forms are legal and valid. Additional information regarding polst and other endoflife resources is on the washington state medical associations website. National polst is the national entity that provides guidance and support to state polst programs. To find your states advance directive form, use our resource statebystate advance directive forms. Draw line through sections a through e and write void across page if any polst form is replaced or becomes invalid.
These medical orders are based on the patients current medical condition and preferences. Although the form is to be signed by a doctor and patient, you can get to know the form and its parts at the coalition for compassionate care of californias website. The polst must be completed by a medical provider mddopaaprn based on patient preferences and medical indications. Here are some helpful tips for moving through fields. To void or modify a polst form, draw a line through sections a through d and write void in large letters on the original and all copies. If a translated form is used with patient or decisionmaker, attach it to the signed english polst form. Polst and dnr forms santa clara county, california. Find out how polst differs from other advance care plans, like advance directives, here. You and your doctor can change your polst form whenever you want. The appointed surrogate decision maker can then sign the polst form on behalf of their loved one. Physician orders for lifesustaining treatment polst is a form that gives seriouslyill patients more control over their endoflife care, including medical treatment, extraordinary measures such as a ventilator or feeding tube and cpr.
Polst and dnr forms california medical decision making forms. The physician orders for life sustaining treatment polst form is a portable physician order form that describes the patients care directions. Printed on bright pink paper, and signed by both a doctor and patient, polst can prevent unwanted or. Eightyseven percent of that cohort had do not resuscitate. Advance health care directive california probate code section 4701 explanation you have the right to give instructions about your own health care.
Faxed copies and photocopies are also valid polst forms. Completion of a polst form without patient or surrogate knowledge is contrary to the purpose and intent of the polst paradigm and violates informed consent and principles of person and familycentered care. The completion of this form is done by the physician and patient, and documents physician orders that adhere to the patients wishes and treatment goals. Advanced health care directive form state of california. California law requires that a polst form be followed by healthcare providers, and provides immunity to those who comply in good faith. Advance health care directive forms 4700 4701 chapter 2 added by stats. This cover sheet should be attached to polst forms distributed at skilled nursing facilities snf. Using polst any incomplete section of polst implies full treatment for that section. Polst form spanish central california alliance for health. Coalition for compassionate care of california is the home. Polst forms and other polst documents for most polst programs may be found and downloaded here. The original polst form, on bright green paper, stays with you at all times. Completed or unsigned polst forms by year and county pdf visual 2.
Polst form completion is always voluntary and should never be mandated. Polst is a tool for medical decision making, and the form should always be introduced in the context of a coversation with a medical professional. Polst form at the moment that treatment decisions are being made. It represents a way of summarizing wishes of an individual regarding life sustaining treatment identified in an advanced directive such as a health care directive or durable power of attorney for. Submit form to post commission on post 860 stillwater road, suite 100 west sacramento, ca 95605 instructions completing a form. Use the filters below to search by state, resource type, file format, and language. Any section not completed does not invalidate the form and implies full treatment for. Photocopies and faxes of signed polst forms are legal and valid. Voiding or revoking a polst form a patient with capacity can void or revoke the form, andor request alternative treatment. The national polst paradigm is an approach to endoflife planning based on conversations between patients, loved ones, and health care professionals designed to ensure that seriously ill or frail patients can choose the treatments they want or do not want and that their wishes are documented and honored. Completion of medical treatment sections by year and county pdf white paper pdf polst form polst related afls. Transfer or discharge patient with a current polst form. The signed polst form must be in english so that emergency personnel can read and follow the orders. Effective october 1, california has updated its physician orders for lifesustaining treatment polst form, the document that physicians can use to record a persons wishes regarding the provision of life sustaining treatment for use in the event of future incapacity.
Personal information update pdf renewal paramedic application packet. Whenever possible, ensure the advance directive if one exists and polst form are consistent with each other. California law requires that a polst form be followed by healthcare providers. A copy should be retained in patients medical record, on ultra pink paper when possible. The most recently dated polst is considered the valid polst and supersede all prior polst directives. Physician orders for lifesustaining treatment polstflorida. The first polst electronic registry was established in oregon in 2009.
This section is applicable in situations where the person has decision making capacity when the polst form is completed. Introduction to the spanish translation of the polst form. The coalition for compassionate care of california has created and compiled a variety of resources to help educate patients, caregivers, and healthcare professionals on the issues both medical and deeply personal surrounding polst. Californias physician orders for lifesustaining treatment. The california do not resuscitate order form dnr is a document that, when signed by a patient and their physician, will prevent emts, paramedics and other emergency personnel from performing any medical procedures on an individual if their heart stops beating, or should they stop breathing. Electronic endoflife and physician orders for life. The polst form is designed to document treatment decisions. Physician orders for lifesustaining treatment forms. The form is often kept on the refrigerator or the back of the front door, and emergency medical teams will look for a polst in those places. Physician orders for lifesustaining treatment polst. To void polst, draw a line through sections a through d and write void in large letters. Physicians orders for lifesustaining treatment polst. A health care professional can complete the polst form based on family members understanding of their loved ones wishes.
Free download california polst form pdf, 151kb and customize with our editable templates, waivers and forms for your needs. This is the organization that advocated for the implementation of polst in california. Free california do not resuscitate dnr order form pdf. Physician orders for lifesustaining treatment polst is a form that gives seriouslyill patients more control over their endoflife care, including medical treatment, extraordinary measures such as a. This form lets you do either or both of these things. The patient should retain the original on terra green colored paper. The physician orders for lifesustaining treatment, polst is a physicians order that outlines a plan of end of life care reflecting both a patients preferences concerning care at lifes end and a physicians judgment based on a medical evaluation. Idph uniform practitioner order for st illinois department of. The form is downloadable in both pdf and microsoft word formats. Provider orders for lifesustaining treatment polst aft. May 01, 2020 california polst form pdf the national polst paradigm is an approach to endoflife planning based on conversations between patients, loved ones, and health care professionals. Completion of medical treatment sections by year and county pdf white paper pdf polst form polstrelated afls.
The statutory advance health care directive form is as follows. Although the form is to be signed by a doctor and patient, you can get to know the form and its parts at the coalition for compassionate care of california s website. California polst form pdf the national polst paradigm is an approach to endoflife planning based on conversations between patients, loved. A polst form also includes directions about lifesustaining measures in addition to cpr, such as intubation, antibiotic use, and feeding tubes.
Physicians orders for life sustaining treatment polst. Ideally, polst forms would be readily accessible via their medical record and would transfer with patients across settings of care, but this doesnt always happen. Polst physician orders for lifesustaining treatment. The polst form is a portable medical order designed to support patients transitioning between facilities or who live outside a facility by communicating patient treatment wishes. Make sure your polst is signed by an md or nurse practitioner in order to be recognized as valid. The polst form is a medical order that gives seriously ill patients more control over their care by specifying the type of medical treatment a patient wishes to receive at the end of life. If orders change complete a new polst and write void across this polst.
Record all treatments entered on this polst as orders in patients chart. Information on how to complete the form, talking to patients or their loved ones about the polst, patient handouts and other important information is available from the nonprofit nevada polst. A copy of the signed polst form is a legally valid physician. Complete a new polst form indicating the modifications. Physician orders for lifesustaining treatment polst form. A polst form differs from a dnr order in one important way. National polst form page 2 attach to page 1 for more information, visit. A surrogate may only void or modify an existing polst form, or execute a new one, if named in this section by the person. Completing polst completing a polst form is voluntary.