POLST
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Physician Orders for Life Sustaining Treatment
POLST patient brochure and form brought to you by the WSMA and the Washington State Department of Health. How to order.
POLST form
View front
and back |
Frequently asked questions
POLST contacts
Downloadable form (for providers only)
Summary of December 2006 form revisions
How to order
Educational DVDs
Registering your POLST form online [NEW] Sample POLST policies
Other resources
Organizations that endorse the use of the POLST Form
Frequently asked questions regarding the POLST form
What is the POLST form?
The Physician Orders for Life-Sustaining Treatment
(POLST) form represents a way of summarizing wishes
of an individual regarding life-sustaining treatment.
The form is intended for any individual with an advanced
life-limiting illness.
The form accomplishes two major purposes:
- It is portable from one care setting to another.
- It translates wishes of an individual into actual
physician orders.
The attending physician, nurse practitioner or PA-C
should complete the document with the patient. The
attending physician, ARNP or PA-C must
sign the form and assume full responsibility for its
accuracy.
The POLST form facilitates the process of translating
end-of-life discussions with patients into actual
treatment decisions, and provides security for the
individual and physician that the expressed wishes
will be carried out. There is no other form that streamlines
the process in this way.
How is the form used?
In a health care facility, the form should be the
first document in the clinical record. It should be
recognized as a set of physician orders, to be implemented
as any physicians orders would. In a non-institutionalized
setting (such as a home), the bright green form should
be located in a prominent location. It will be recognized
by emergency personnel as orders to be followed.
How is the form transferred from
one setting to another?
The original green form must be transferred with the
individual to be valid. The institution may wish to
keep a duplicated copy in the permanent medical record
upon discharge.
If I have a POLST form, do I
need an advance directive, too?
We encourage everyone to have an Advance Directive,
like a Durable Power of Attorney for Healthcare and/or
Living Will. While Advance Directives are often very
helpful in determining end-of-life decisions, they
are not required or necessary for having a POLST form.
You may obtain more information about Advance Directives
from your physician, your health insurance provider,
or here. Back to top
POLST contacts
The volunteer health professionals below are willing to help
answer any questions you might have regarding POLST. These volunteers come from
a variety of health professions; choose the one most
closely related to the subject of your query.
Bill Bender, MD, (509) 456-7200, general information
Sally Denton, RN, (509) 474-2161, nursing home perspective
Sharmon Figenshaw, ARNP, CHPN, (425) 303-1718 (pager), hospice/palliative care perspective
Ginny Kreindl, RN, (360) 734-4181, nursing home perspective
Karen Ssebanakitta, RN, MN, (360) 715-4121, hospital perspective
Jim Shaw, MD, (509) 474-3008, physician perspective Back to top
Downloadable POLST form (for providers only)
Instructions on how to download a master copy of the POLST form to make your own copies for distribution.
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Summary of December 2006 form revisions
A summary of revisions made to
the POLST form in December of 2006.
Back to top
How to order POLST forms and patient brochures
Patients: Patients are
encouraged to ask their physicians for the form, but
may also obtain a form by sending a self-addressed,
stamped envelope to WSMA, Attn: POLST, 2033 Sixth
Avenue, Suite 1100, Seattle, WA 98121.
If you are a WSMA member, or ordering on behalf of a WSMA member, order
bulk supplies of POLST forms and patient brochures by using our online order form.
Non-WSMA members will need to send in their order with pre-payment. Instructions on how to calculate cost and order with pre-payment.
We'd like to encourage any and all institutions to
consider printing their own copies of the POLST form.
To help you do this, we provide a master
copy of the form for you to print and use to make
copies, as well as instructions as to the type of
paper you need. Back to top
Educational DVDs
"POLST Choices for end of life"
This educational film (on DVD) demonstrates
the latest information and techniques for discussing
choices with patients and families. It covers, section-by-section, how to complete the POLST form. Whether the person preparing the form is a physician,
NP, PA-C, or a nursing home staff member preparing
the form for the MD or NP to review and sign, the DVD is designed to help the preparer to skillfully
engage patients and families about their treatment
options. You can use the DVD for in-service trainings. The DVD is $10. To order, send a check or money order made out to WSMA to: Attn: "POLST Choices for end of life", 2033 Sixth Ave, Ste 1100, Seattle, WA 98121. View a streaming version of the DVD on your computer.
"Honoring the Wishes of the Spanish
Speaking Patient & Family."
This educational film (on DVD) illustrates how POLST can be effective in
honoring a person's wishes, while remaining sensitive to the role that family
and culture often play in end-of-life decisions. This DVD pays particular attention to those whose first language
is Spanish, yet we also believe that it is a wonderful resource for all who are
interested in learning more about POLST.
The film is available on a single DVD in both
Spanish and English. The DVD is currently available for free. To order a copy, contact Graham Short, (206) 956-3633. Back to top
Registering your POLST form online
You can now record your POLST form online via the Washington
State Living Will Registry. The Registry is designed to preserve
Washington State residents’ final wishes by recording advance
directives (Living Will and/or Durable Power of Attorney for Health Care), as well as other end-of-life documents, including the POLST form and Mental Health Advance Directives.
Your family members will be comforted knowing that your treatment
choices are up-to-date and accurate. Take charge of your life and
document your decisions at www.doh.wa.gov/livingwill or call 1.800.525.0127 today.
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Sample POLST policies
Sample polices for hospitals and nursing homes can be found at the Association
of Washington Public Hospital Districts End of Life website
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Other POLST resources on the Web
Department
of Health POLST website
Association
of Washington Public Hospital Districts End of Life website
Oregon's
POLST website
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Organizations that endorse the use of the POLST form
- Association of Washington Public Hospital Districts
- Washington State Department of Health
- Washington State Hospice & Palliative Care
Organization
- Washington State Hospital Association
- Washington State Medical Association
- Regional Ethics Network of Eastern Washington
and Northern Idaho
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