What are the different components of a POLST Form?

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Section A: Cardiopulmonary Resuscitation (CPR)

These orders apply only when a person has no pulse and is not breathing; this section does not apply to any other medical circumstance.  If a person wants CPR, the “attempt resuscitation/CPR” box should be checked.  If a person does not want CPR, the “do not attempt resuscitation/DNR” box should be checked.

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Section B: Medical Interventions 

This section is designed to guide care in an situation when the person is not in cardiopulmonary arrest. There are three levels of medical interventions found on POLST forms:

  1. Comfort Measures Only/Allow Natural Death. The treatment plan is to maximize comfort through symptom management. This box should be check if a person’s goal is to maximize comfort and not go to the hospital unless necessary (comfort needs cannot be met).

  2. Limited Treatment. The treatment plan is to go to the hospital if needed but to avoid mechanical ventilation and generally avoid the intensive care unit (ICU). This should be ordered if a person’s goal is to get treatments for reversible conditions or a worsening underlying disease with the goal of restoring a person to their current state of health. Examples include going to the hospital for dehydration or for pneumonia.

  3. Full Treatment. The treatment plan should include all life-sustaining treatments possible, including intubation, advanced airway intervention, mechanical ventilation, and cardioversion.