Provider Order for Life-Sustaining Treatment (POLST)
Utah Life with Dignity Order
Bureau of Health Facility Licensing and Certification, Utah Department of Health
State of Utah Rule R432-31 v3.1 February 2016 (http://health.utah.gov/hflcra/forms.php)
COMPLETING POLST
- This form is intended for both adult and pediatric patients.
- The POLST is not an Advance Directive and does not replace it. The POLST is a Medical Order.
- When available, review the Advance Directive and POLST form to ensure consistency.
- The POLST must be completed by a medical provider (MD/DO/PA/APRN) based on patient preferences and medical indications.
- The entire form should be completed. A patient may indicate that they “do not wish to express a preference” rather than leaving a
section of the form blank.
- Section D, which indicates the degree of leeway the patient would like to grant their surrogate, must be completed by the
individual patient and only if the patient has medical decision-making capacity.
- The POLST must be signed by the patient or surrogate decision maker AND by a medical provider (MD/DO/PA/APRN) to be valid.
In the case of pediatric patients, signatures from two different medical providers are required.
- Use of the original form is strongly encouraged. Photocopies and FAXs of signed POLST forms are legal and valid.
USING POLST
Section A:
- If a patient has selected “Do Not Attempt Resuscitation” and is found pulse less and not breathing, no defibrillator (including
automated external defibrillators) or chest compressions should be used.
Section B:
- A person may chose “DNR” in Section A and “Full Treatment” in Section B, recognizing in Section A the setting refers to where
there are no signs of life (palpable pulse) and Section B refers to the setting where there are signs of life.
- Choosing “Attempt to resuscitate” in Section A requires “Full treatment” in Section B as an attempt at resuscitation may include
endotracheal intubation, mechanical ventilation, defibrillation/ cardioversion, and/or vasopressors.
- When comfort cannot be achieved in the current setting, the patient, including someone with “Comfort Measures,” may be
transferred to the hospital to provide comfort (e.g., treatment of hip fracture).
- If a patient has indicated that he/she would not want to return to the hospital, this should be written in the “other instructions and
clarifications” section of the form.
- IV antibiotics and fluids are generally not considered “Comfort Measures” and may prolong life. A person who desires IV fluids or IV
antibiotics should indicate “Limited Additional Interventions” or “Full Treatment.”
- Some IV medications (e.g. medication for pain, nausea, delirium, etc.) may be appropriate for a patient who has chosen “Comfort
Measures.”
REVIEWING POLST
This form should be reviewed periodically (consider at least annually). Review is also recommended when:
- The patient is transferred from one care setting or care level to another.
- There is a substantial change in the patient’s health status.
- The patient’s treatment preferences change.
MODIFYING AND VOIDING POLST
- The POLST form can be modified at any time if a patient changes his/her mind about his/her treatment preferences by completing
a new POLST form.
- If a patient has given sufficient leeway to his/her surrogate to modify the POLST form, any modifications made should be
consistent with patient preferences and in collaboration with the medical provider.
- It is recommended that revocation of the form be documented by drawing a line through sections A through D, writing “VOID” in
large letters, and signing/dating the form.
- The most recently dated POLST is considered the valid POLST. The most recently dated POLST orders supersede all prior POLST
directives.
Place this form in a prominently visible part of the patient’s record or home. A copy of this form must accompany the patient when
transferred or discharged (including transfers to hospital emergency departments).
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DIRECTIONS FOR HEALTHCARE PROVIDERS
