POLST forms are different in each state — the order of the sections or the options within a section may be different — but they cover the same information. Below provides information about the forms.
Section A: Cardiopulmonary Resuscitation (CPR)
This section only applies when the patient is unresponsive, has no pulse and is not breathing; this section does not apply to any other medical circumstance. If the patient wants CPR, the box should be checked and full CPR measures should be carried out and 9-1-1 called. If the patient does not want CPR, the box should be checked and CPR should not be performed.
This is similar to a Do-No-Resuscitate Order (DNR Order), but a patient only has a DNR Order when they do not want CPR. The POLST Paradigm Form allows patients to clearly show they do want CPR.
If this is left blank, emergency personnel will provide CPR if medically indicated.
Section B: Medical Interventions
This section gives medical orders when CPR is not required but the patient still has a medical emergency and cannot communicate. There are three options and a space for a health care professional to write in orders specific for the patient. Care is always provided to patients. This section is just for letting emergency personnel know what treatments the patient wants to have.
- Full Treatment. The goal of this option is to provide all treatments necessary (and medically appropriate) to keep the patient alive. The treatment plan should include all life-sustaining treatments possible, including intubation, advanced airway intervention, mechanical ventilation, cardiodiversion, transfer to hospital and use of intensive care as indicated with no limitation of treatment.
- Limited Treatment/Select Treatment. The goal of this option is to provide basic medical treatments. The treatment plan is to hospitalize if needed but to avoid mechanical ventilation and generally avoid ICU care. This should be ordered if a patient’s goal is to obtain treatments for reversible conditions or exacerbations of his/her underlying disease with the goal of restoring the patient to his/her current state of health.
- Comfort Measures Only/Allow Natural Death. The treatment plan is to maximize comfort through symptom management. This should be ordered if a patient’s goal is to maximize comfort and avoid hospitalizations unless necessary to ensure comfort needs are met. Antibiotics may be used as a comfort measure.
In many states, if a patient chooses CPR or leaves Section A blank, “Full Treatment” is required in Section B. This is because CPR usually requires intubation and a breathing machine, which are only options under “Full Treatment”.
This section is the heart of the POLST form. If a patient has a medical emergency but does not want CPR this is the section emergency personnel will look at to see whether the patient wants to go to the hospital or not (for Full Treatment and Limited Interventions- yes; for Comfort Measures Only- no). If the patient only has a DNR order, emergency personnel would take them to the hospital.
Section C: Artificially Administered Nutrition
This section is where orders are given about artificial nutrition (and in some states artificial hydration) for when the patient cannot eat. All POLST forms clearly state that fluids and nutrition will be provided if medically feasible.
Other Section: Signatures
Healthcare professional: Since this form is a medical order a health care professional is required to sign it in order for it to be valid. Which health care professionals can sign (nurse, doctor, physician assistant) varies by state. The form has a statement saying that, by signing the form, the healthcare professional agrees that the orders on the form match what treatments the patient said he/she wanted during a medical emergency based on his/her medical condition today.
Patient or Surrogate: Most states require the patient or his/her surrogate to sign this form. This helps to show the patient or surrogate was part of the conversation and agrees with the orders listed on the form.
Back Side of a POLST Form
The backside of the POLST form has directions and information, usually for healthcare professionals. Other information it may have includes:
- Information on how to void a POLST form;
- Contact information for surrogates; and
- Information on who completed the POLST form.