The Provider Orders for Life-Sustaining Treatment (POLST) form in Hawaii is a medical document that outlines a patient's preferences for medical treatment in emergency situations. It is designed to ensure that individuals receive care that aligns with their wishes, especially when they are unable to communicate those wishes themselves. Understanding the POLST form is crucial for both patients and healthcare providers to facilitate respectful and appropriate medical care.
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The Hawaii Provider Orders for Life-Sustaining Treatment (POLST) form serves as a crucial document for individuals facing serious health conditions. It is designed to communicate a patient's preferences regarding medical treatment in emergencies, ensuring that their wishes are respected and followed by healthcare providers. The POLST form outlines specific medical interventions, such as whether to perform cardiopulmonary resuscitation (CPR) or to provide comfort measures only. It includes sections that detail the patient's desires concerning artificial nutrition and hydration, as well as any additional orders that may be necessary. Importantly, the form must be completed and signed by a licensed physician or advanced practice registered nurse, in conjunction with the patient or their legally authorized representative. This collaborative process ensures that the orders reflect the individual's current medical condition and personal wishes. HIPAA regulations allow for the sharing of the POLST form with other healthcare professionals, facilitating seamless care transitions. The form is not static; it should be reviewed periodically, especially when a patient's health status changes or when they are transferred between care settings. By providing clear guidance on treatment preferences, the POLST form empowers patients and their families during challenging times, fostering dignity and respect in the face of serious illness.
HIPAA PERMITS DISCLOSURE OF POLST TO OTHER HEALTH CARE PROFESSIONALS AS NECESSARY
PROVIDER ORDERS FOR LIFE-SUSTAINING TREATMENT (POLST) - HAWAI‘I
FIRST follow these orders. THEN contact the
Paient’s Last Name
paient’s provider. This Provider Order form is
based on the person’s current medical condiion
First/Middle Name
and wishes. Any secion not completed implies
full treatment for that secion. Everyone shall be
Date of Birth
Date Form Prepared
treated with dignity and respect.
A
CARDIOPULMONARY RESUSCITATION (CPR): ** Person has no pulse and is not breathing **
Atempt Resuscitaion/CPR
Do Not Atempt Resuscitaion/DNAR (Allow Natural Death)
Check
(Secion B: Full Treatment required)
One
If the paient has a pulse, then follow orders in B and C.
B
MEDICAL INTERVENTIONS:
** Person has pulse and/or is breathing **
Comfort Measures Only Use medicaion by any route, posiioning, wound care and other measures to relieve pain
and suffering. Use oxygen, sucion and manual treatment of airway obstrucion as needed for comfort. TRANSFER IF COMFORT
needs cannot be met in current locaion.
Limited Addiional Intervenions Includes care described above. Use medical treatment, anibioics, and IV fluids as indicated. Do not intubate. May use less invasive airway support (e.g. coninuous or bi-level posiive airway pressure). TRANSFER to hospital if indicated. Avoid intensive care.
Full Treatment Includes care described above. Use intubaion, advanced airway intervenions, mechanical venilaion, and defibrillaion/cardioversion as indicated. TRANSFER to hospital if indicated. Includes intensive care.
Addiional Orders:
C
ARTIFICIALLY ADMINISTERED NUTRITION: Always offer food and liquid by mouth if feasible
(See Direcions on next page for informaion on nutriion & hydraion)
and desired.
No arificial nutriion by tube.
Defined trial period of arificial nutriion by tube.
Long-term arificial nutriion by tube.
Goal:
D
SIGNATURES AND SUMMARY OF MEDICAL CONDITION - Discussed with:
Paient or
Legally Authorized Representaive (LAR). If LAR is checked, you must check one of the boxes below:
Guardian
Agent designated in Power of Atorney for Healthcare
Paient-designated surrogate
Surrogate selected by consensus of interested persons (Sign secion E)
Parent of a Minor
Signature of Provider (Physician/APRN licensed in the state of Hawai‘i.)
My signature below indicates to the best of my knowledge that these orders are consistent with the person’s medical condiion and preferences.
Print Provider Name
Provider Phone Number
Date
Provider Signature (required)
Provider License #
Signature of Paient or Legally Authorized Representaive
My signature below indicates that these orders/resuscitaive measures are consistent with my wishes or (if signed by LAR) the known wishes and/or in the best interests of the paient who is the subject of this form.
Signature (required)
Name (print)
Relaionship (write ‘self’ if paient)
Summary of Medical Condiion
Official Use Only
SEND FORM WITH PERSON WHENEVER TRANSFERRED OR DISCHARGED
Paient Name (last, first, middle)
Gender
M F
Patient’s Preferred Emergency Contact or Legally Authorized Representative
Name
Address
Phone Number
Health Care Professional Preparing Form
Preparer Title
E
SURROGATE SELECTED BY CONSENSUS OF INTERESTED PERSONS
(Legally Authorized Representaive as outlined in secion D)
I make this declaraion under the penalty of false swearing to establish my authority to act as the legally authorized represen-
taive for the paient named on this form. The paient has been determined by the primary physician to lack decisional
capacity and no health care agent or court appointed guardian or paient-designated surrogate has been appointed or the agent or guardian or designated surrogate is not reasonably available. The primary physician or the physician’s designee has made reasonable efforts to locate as many interested persons as pracicable and has informed such persons of the paient's lack of capacity and that a surrogate decision-maker should be selected for the paient. As a result I have been selected to act as the paient’s surrogate decision-maker in accordance with Hawai‘i Revised Statutes §327E-5. I have read secion C below and understand the limitaions regarding decisions to withhold or to withdraw arificial hydraion and nutriion.
Relaionship
Compleing POLST
DIRECTIONS FOR HEALTH CARE PROFESSIONAL
•Must be completed by health care professional based on paient preferences and medical indicaions.
•POLST must be signed by a Physician or Advanced Pracice Registered Nurse (APRN) licensed in the state of Hawai‘i and the paient or the paient’s legally authorized representaive to be valid. Verbal orders by providers are not acceptable.
•Use of original form is strongly encouraged. Photocopies and FAXes of signed POLST forms are legal and valid.
Using POLST
• Any incomplete secion of POLST implies full treatment for that secion. Secion A:
• No defibrillator (including automated external defibrillators) should be used on a person who has chosen “Do Not Atempt Resuscitaion.”
Secion B:
•When comfort cannot be achieved in the current seing, the person, including someone with “Comfort Measures Only,” should be transferred to a seing able to provide comfort (e.g., treatment of a hip fracture).
•IV medicaion to enhance comfort may be appropriate for a person who has chosen “Comfort Measures Only.”
•A person who desires IV fluids should indicate “Limited Intervenions” or “Full Treatment.”
Secion C:
• A paient or a legally authorized representaive may make decisions regarding arficial nutriion or hydraion. However, a surrogate who has not been designated by the paient (surrogate selected by consensus of interested persons) may only make a decision to withhold or withdraw arificial nutriion and hydraion when the primary physician and a second independent physician cerify in the paient’s medical records that the provision or coninuaion of arificial nutriion or hydraion is merely prolonging the act of dying and the paient is highly unlikely to have any neurological response in the future. HRS §327E-5.
Reviewing POLST
It is recommended that POLST be reviewed periodically. Review is recommended when:
•The person is transferred from one care seing or care level to another, or
•There is a substanial change in the person’s health status, or
•The person’s treatment preferences change.
Modifying and Voiding POLST
•A person with capacity or, if lacking capacity the legally authorized representaive, can request a different treatment plan and may revoke the POLST at any ime and in any manner that communicates an intenion as to this change.
•To void or modify a POLST form, draw a line through Secions A through E and write “VOID” in large leters on the original and all copies. Sign and date this line. Complete a new POLST form indicaing the modificaions.
•The paient’s provider may medically evaluate the paient and recommend new orders based on the paient’s current health status and goals of care.
Kōkua Mau – Hawai‘i Hospice and Palliaive Care Organizaion
Kōkua Mau is the lead agency for implementaion of POLST in Hawai‘i. Visit www.kokuamau.org/polst to download a copy
or find more POLST informaion. This form has been adopted by the Department of Health July 2014
Kōkua Mau • PO Box 62155 • Honolulu HI 96839 • [email protected] • www.kokuamau.org
Completing the Hawaii POLST form involves several steps to ensure that the patient's medical preferences are accurately recorded. Following these instructions will help facilitate a clear understanding of the patient's wishes regarding medical treatment and interventions.
The Hawaii Provider Orders for Life-Sustaining Treatment (POLST) form is a medical order that outlines a person's preferences for medical treatment in emergency situations. It is designed for individuals with serious illnesses or those who may be nearing the end of life. The form is based on the person’s current medical condition and wishes, ensuring that healthcare providers follow their preferences regarding life-sustaining treatments.
A healthcare professional, such as a physician or an Advanced Practice Registered Nurse (APRN), must complete the POLST form. This professional should discuss the patient's treatment preferences and medical indications with them or their legally authorized representative. The form must be signed by both the healthcare provider and the patient or their representative to be valid.
If any section of the POLST form is left incomplete, it implies that full treatment is desired for that section. For instance, if the section regarding resuscitation is not filled out, it will be interpreted as a request for full resuscitation efforts.
Yes, a person with capacity or their legally authorized representative can modify or revoke the POLST at any time. To void the form, one should draw a line through all sections and write “VOID” on the original and all copies. It is also necessary to sign and date this change. A new POLST form can then be completed to indicate the modifications.
The POLST form should accompany the patient whenever they are transferred or discharged from a healthcare facility. This ensures that all healthcare professionals involved in the patient's care are aware of their treatment preferences and can follow the orders specified in the POLST form.
The POLST form should be reviewed periodically, especially when there is a transfer between care settings, a significant change in the patient's health status, or a change in the patient's treatment preferences. Regular reviews help ensure that the form accurately reflects the patient's current wishes and medical condition.
The POLST form allows patients to specify their preferences regarding artificially administered nutrition. Options include:
Kōkua Mau is the lead agency for implementing the POLST program in Hawaii. They provide resources and support for healthcare professionals and patients regarding the POLST form. More information, including downloadable copies of the form, can be found on their website.
Failing to complete all sections of the form. Each section must be filled out to ensure that the patient's wishes are clearly expressed. Incomplete sections may imply full treatment, which might not align with the patient’s desires.
Not discussing the form with the patient or their legally authorized representative. It is essential to have a conversation about the patient's medical condition and treatment preferences before filling out the POLST form.
Using outdated information. The POLST form should reflect the patient’s current medical condition and wishes. Regular reviews are necessary, especially after health changes.
Neglecting to obtain the required signatures. Both the healthcare provider and the patient or their legally authorized representative must sign the form for it to be valid.
Not providing a copy of the POLST form to the patient. It is important that the patient has access to their POLST form for their records and to share with other healthcare providers.
Forgetting to review the POLST when transferring care settings. The form should be reassessed whenever a patient moves to a different care environment to ensure it remains applicable.
Misunderstanding the implications of “Do Not Attempt Resuscitation” (DNAR). Selecting this option means that no resuscitation efforts should be made if the patient has no pulse or is not breathing.
Overlooking the importance of discussing artificial nutrition and hydration. Patients or their representatives should clearly indicate their preferences regarding these treatments on the form.
Failing to provide accurate contact information for the healthcare professional preparing the form. This information is crucial for any follow-up or clarification needed by other providers.
Not understanding the role of a surrogate decision-maker. If a surrogate is selected, it is important to ensure that they are aware of the patient’s wishes and the limitations of their decision-making authority.
The Hawaii POLST form is an important document that helps ensure a person’s medical wishes are respected during serious health situations. Along with the POLST form, several other documents can support healthcare decisions and provide clarity about a person's preferences. Here are five key forms and documents often used in conjunction with the POLST:
Using these documents together with the POLST form can provide a clearer picture of a person's healthcare preferences. It's important to have these conversations and ensure that all relevant documents are in place, so that wishes are honored during critical times.
The Hawaii POLST form is similar to an Advance Directive, which allows individuals to outline their preferences for medical treatment in advance. Like the POLST, an Advance Directive ensures that healthcare providers understand a person’s wishes regarding life-sustaining treatment. Both documents serve to communicate a patient’s desires when they may not be able to speak for themselves, but an Advance Directive is generally broader and can cover a range of medical decisions beyond just end-of-life care.
Another document comparable to the Hawaii POLST is a Living Will. This legal document specifies what medical treatments a person does or does not want in the event they become incapacitated. Similar to the POLST, a Living Will focuses on the individual's preferences for treatment, particularly in critical situations. However, a Living Will is often more limited in scope, while the POLST can provide detailed orders for specific medical interventions.
The Medical Power of Attorney is also akin to the Hawaii POLST. This document designates a specific person to make healthcare decisions on behalf of someone who is unable to do so. While the POLST outlines specific medical orders, the Medical Power of Attorney grants decision-making authority to a trusted individual. Both documents aim to ensure that a person’s wishes are respected when they cannot communicate them directly.
A Do Not Resuscitate (DNR) order shares similarities with the POLST form. A DNR specifically instructs healthcare providers not to perform CPR if a patient stops breathing or their heart stops beating. While the POLST can include a DNR directive, it also covers a broader range of medical interventions and preferences. Both documents prioritize patient autonomy in end-of-life care.
The Physician Orders for Life-Sustaining Treatment (POLST) is also similar to the Comfort Care Order. This document emphasizes the provision of comfort measures rather than aggressive treatments. Like the POLST, the Comfort Care Order focuses on the patient’s comfort and quality of life, especially in terminal situations. Both documents guide healthcare providers in delivering care aligned with the patient’s wishes.
Another related document is the Health Care Proxy. This allows an individual to appoint someone to make medical decisions on their behalf. Similar to the POLST, the Health Care Proxy ensures that a person's healthcare preferences are respected. However, the POLST provides specific medical orders, while the Health Care Proxy focuses on who will make decisions if the person is unable to do so.
Lastly, a Treatment Plan can be compared to the Hawaii POLST. A Treatment Plan outlines the medical care a patient will receive based on their health condition and goals. Like the POLST, it is tailored to the individual’s needs and preferences. However, a Treatment Plan is usually created by healthcare providers, while the POLST emphasizes the patient’s own choices regarding their care.
When filling out the Hawaii POLST form, it's essential to ensure accuracy and clarity to reflect the patient's wishes and medical conditions. Here are five important do's and don'ts to consider:
Following these guidelines can help ensure that the POLST form accurately reflects the patient's wishes and provides the necessary care in accordance with their preferences.
Understanding the Hawaii POLST form is crucial for patients and their families. However, several misconceptions can lead to confusion. Here are eight common misunderstandings about the POLST form:
Clarifying these misconceptions can help ensure that patients receive the care they desire and deserve. Understanding the POLST form is a vital step in making informed healthcare decisions.
Filling out and using the Hawaii POLST form can be a crucial step in ensuring that a person’s healthcare wishes are respected. Here are some key takeaways to keep in mind:
These key points can help guide individuals and their families in using the Hawaii POLST form effectively. Understanding the form and its implications can lead to better healthcare outcomes that align with personal wishes.