Form helps families plan for patient’s demise

Patient/family wishes at a glance

In Oregon, physicians routinely use the Physician Order for Life Sustaining Treatment (POLST) form to summarize patient’s advance directives. The two-page, bright pink form is part of the patient’s record.

The POLST form contains the following seven sections:

Section A: Resuscitation.

o Resuscitate.

o Do not resuscitate.

Section B: Medical Interventions.

o Comfort measures only.

o Limited interventions.

o Advanced interventions.

o Full treatment/resuscitation.

Section C: Antibiotics.

o No antibiotics except if needed for comfort.

o No invasive (IM/IV) antibiotics.

o Full treatment.

Section D: Artificially administered fluids and nutrition.

o No feeding tubes/IV fluids.

o No long-term feeding tubes/ IV fluids.

o Full treatment.

Section E: Discussed with:

o Patient/resident.

o Health care representative.

o Court-appointed guardian.

o Spouse.

o Other (specify).

Section F: Patient/resident preferences as a guide for the POLST form.

Section G: Review of this POLST form.

The Center for Ethics recommends that the form be reviewed periodically and modified to reflect any significant changes in the patient’s health status, care setting, or expressed preferences. A POLST kit is available from the Center for Ethics. The form and POLST wallet cards are available at a minimal fee, as well.

[Editor’s note: To receive a POLST kit, contact: Oregon Health Sciences University, Center for Ethics in Health Care, 3181 SW Sam Jackson Park Road, Mail code L101, Portland, OR 97201-3098. Phone: (503) 494-4466. Fax: (503) 494-1260. E-mail: tolles]