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Overview

The Hawaii Provider Orders for Life-Sustaining Treatment (POLST) form is a crucial document designed to communicate a patient's healthcare preferences in emergency situations. This form outlines specific medical orders based on an individual's current health condition and personal wishes, ensuring that medical professionals respect the patient's desires. Key sections of the POLST include directives on cardiopulmonary resuscitation (CPR), medical interventions, and artificially administered nutrition. For instance, patients can choose between full treatment, limited interventions, or comfort measures only, depending on their health status. Additionally, the form allows for the designation of a legally authorized representative to make decisions if the patient is unable to do so. Importantly, the POLST must be signed by a physician or an Advanced Practice Registered Nurse (APRN) to be valid, and it should accompany the patient whenever they are transferred or discharged. Understanding the POLST is essential for both patients and healthcare providers, as it serves as a vital tool in ensuring that care aligns with the patient's values and preferences.

Document Preview Example

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

Check

and suffering. Use oxygen, sucion and manual treatment of airway obstrucion as needed for comfort. TRANSFER IF COMFORT

One

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.

 

Check

No arificial nutriion by tube.

Defined trial period of arificial nutriion by tube.

 

One

Long-term arificial nutriion by tube.

Goal:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Addiional Orders:

 

 

 

 

 

 

 

 

 

 

 

 

 

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:

 

 

 

Check

 

 

 

 

 

 

 

Guardian

Agent designated in Power of Atorney for Healthcare

Paient-designated surrogate

 

One

 

 

 

 

 

 

 

 

 

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

HIPAA PERMITS DISCLOSURE OF POLST TO OTHER HEALTH CARE PROFESSIONALS AS NECESSARY

Paient Name (last, first, middle)

Date of Birth

Gender

M F

Patient’s Preferred Emergency Contact or Legally Authorized Representative

Name

Address

 

Phone Number

 

 

 

 

Health Care Professional Preparing Form

Preparer Title

Phone Number

Date Form Prepared

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.

 

Signature (required)

Name

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 • info@kokuamau.org • www.kokuamau.org

SEND FORM WITH PERSON WHENEVER TRANSFERRED OR DISCHARGED

How to Fill Out Hawaii Polst

Filling out the Hawaii POLST form is a crucial step in ensuring that medical preferences are respected. This form captures the patient's wishes regarding life-sustaining treatment and should be completed carefully. Below are the steps to guide you through the process.

  1. Begin by entering the patient's Last Name, First/Middle Name, and Date of Birth.
  2. Indicate the Date Form Prepared.
  3. In Section A, determine the patient's wishes regarding Cardiopulmonary Resuscitation (CPR). Choose between:
    • Atempt Resuscitation/CPR if the patient has no pulse and is not breathing.
    • Do Not Attempt Resuscitation/DNAR if the patient prefers to allow natural death.
  4. Move to Section B for Medical Interventions. Select one of the following options based on the patient's condition:
    • Comfort Measures Only for pain relief and comfort.
    • Limited Additional Interventions for some medical treatments but no intubation.
    • Full Treatment for all medical interventions, including intensive care.
  5. In Section C, indicate the patient's preferences for Artificially Administered Nutrition. Choose one option:
    • Always offer food and liquid by mouth if feasible.
    • No artificial nutrition by tube.
    • Defined trial period of artificial nutrition by tube.
    • Long-term artificial nutrition by tube.
  6. In Section D, discuss the form with the patient or their Legally Authorized Representative (LAR). If the LAR is signing, indicate their relationship to the patient.
  7. Ensure that the Signature of Provider is included. The provider must print their name, phone number, and license number.
  8. Obtain the Signature of Patient or LAR. This signature confirms that the orders align with the patient’s wishes.
  9. Complete the Summary of Medical Condition section.
  10. Finally, ensure that the form is sent with the patient whenever they are transferred or discharged.

Common mistakes

Filling out the Hawaii POLST form can be a crucial task, yet many people make common mistakes that can lead to confusion or miscommunication about their medical wishes. Here are ten mistakes to avoid when completing this important document.

First, one of the biggest errors is not signing the form. The POLST must be signed by both the healthcare provider and the patient or their legally authorized representative. Without these signatures, the form is not valid. Always double-check that all required signatures are present.

Second, many individuals forget to provide complete information in the personal details section. Missing or incorrect names, dates of birth, or contact information can lead to complications. Ensure that all personal details are accurate and clearly written.

Third, people often overlook the importance of discussing the form with their healthcare provider. The POLST should reflect the patient’s current medical condition and preferences. Failing to have this conversation can result in orders that do not align with the patient’s wishes.

Fourth, individuals sometimes misunderstand the implications of leaving sections incomplete. If a section is not filled out, it implies full treatment for that section. This can lead to unwanted interventions. Be sure to carefully consider each section and mark it according to your wishes.

Fifth, there can be confusion regarding the CPR section. If someone chooses “Do Not Attempt Resuscitation,” they should ensure that this choice is clearly marked. Misunderstandings in this area can lead to distressing situations for patients and families.

Sixth, people may not realize that the POLST form should be reviewed regularly. Changes in health status or treatment preferences should prompt a review of the document. Keeping the POLST updated is vital for ensuring that it remains aligned with the patient’s wishes.

Seventh, individuals sometimes neglect to discuss the POLST with family members. Having open conversations about end-of-life wishes can help ensure that everyone is on the same page. This can prevent confusion and conflict later on.

Eighth, some people mistakenly believe that a verbal order from a healthcare provider is sufficient. However, the POLST must be in writing and signed by a licensed physician or APRN. Always use the original form to avoid any issues with validity.

Ninth, a common oversight is failing to specify preferences for artificially administered nutrition. Patients need to indicate whether they want artificial nutrition and hydration, and if so, for how long. This decision is crucial and should be made thoughtfully.

Lastly, individuals may not understand the role of a legally authorized representative. If a surrogate decision-maker is needed, it’s essential to choose someone who understands the patient’s wishes. This person should be clearly identified on the form to avoid any confusion.

By avoiding these common mistakes, individuals can ensure that their Hawaii POLST form accurately reflects their medical preferences and protects their wishes. Taking the time to carefully complete this form can provide peace of mind for both patients and their families.

Documents used along the form

The Hawaii POLST (Provider Orders for Life-Sustaining Treatment) form is an essential document that outlines a patient's preferences regarding medical treatment in emergency situations. However, it is often accompanied by other important forms and documents that help ensure a comprehensive approach to patient care. Below is a list of some commonly used documents that work alongside the POLST form.

  • Advance Healthcare Directive: This document allows individuals to specify their healthcare preferences and appoint a healthcare agent to make decisions on their behalf if they become unable to do so. It complements the POLST by providing broader instructions about a person's wishes.
  • Durable Power of Attorney for Healthcare: This form designates a specific person to make healthcare decisions for someone if they are incapacitated. It is crucial for ensuring that the appointed agent can advocate for the patient's wishes as outlined in the POLST.
  • Living Will: A living will details a person's preferences regarding life-sustaining treatments in situations where they are terminally ill or in a persistent vegetative state. This document can guide decisions made by healthcare providers and agents.
  • Do Not Resuscitate (DNR) Order: A DNR order is a specific request not to have CPR performed if the heart stops or breathing ceases. This order can be included in the POLST but may also be issued separately by a physician.
  • Healthcare Proxy: This document allows individuals to appoint someone to make medical decisions on their behalf. It is similar to a durable power of attorney but focuses specifically on healthcare decisions.
  • Medication Administration Record (MAR): This record tracks medications prescribed to a patient, including dosages and administration times. It is vital for ensuring that any treatments outlined in the POLST are followed correctly.
  • Texas Certificate of Insurance: This document ensures that Responsible Master Plumbers maintain adequate insurance coverage for their plumbing activities, protecting both the plumber and the public. For more information on filling out this form, visit Texas Documents.
  • Patient's Medical History: A comprehensive medical history provides healthcare professionals with vital information about a patient's previous conditions, treatments, and allergies, which can influence the implementation of POLST orders.
  • Consent for Treatment Form: This form is used to obtain permission from the patient or their representative before administering any medical treatment. It ensures that the patient's rights are respected and that they are informed about their care.
  • Transfer Orders: When a patient is moved from one care setting to another, transfer orders ensure that all relevant medical information, including POLST, is communicated effectively to the new healthcare team.
  • Patient Information Sheet: This document provides essential information about the patient, including emergency contacts and specific medical needs. It helps healthcare providers deliver personalized care in accordance with the POLST.

Each of these documents plays a vital role in ensuring that a patient's healthcare preferences are honored and that their rights are protected. Together, they create a framework for respectful and informed medical care, particularly in critical situations where decisions must be made swiftly.

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Obtain Answers on Hawaii Polst

What is the purpose of the Hawaii POLST form?

The Hawaii Provider Orders for Life-Sustaining Treatment (POLST) form serves as a medical order that outlines a patient's preferences regarding life-sustaining treatments. It is designed for individuals with serious illnesses or those nearing the end of life. The POLST form ensures that a patient's wishes are honored by healthcare providers, especially in emergency situations where decisions about treatment must be made quickly.

Who should complete the POLST form?

The POLST form should be completed by a healthcare professional, such as a physician or an Advanced Practice Registered Nurse (APRN), who is familiar with the patient’s medical condition and treatment preferences. It is crucial that the form reflects the patient’s current wishes and medical status. Patients themselves or their legally authorized representatives should also sign the form to validate it.

What happens if a section of the POLST form is left blank?

If any section of the POLST form is left incomplete, it is interpreted as a directive for full treatment in that area. This means that healthcare providers will assume the patient desires all available medical interventions unless specified otherwise. Therefore, it is essential to carefully consider and fill out each section of the form to ensure that it accurately reflects the patient's wishes.

Can the POLST form be modified or revoked?

Yes, the POLST form can be modified or revoked at any time by the patient or their legally authorized representative, provided the patient has the capacity to make such decisions. To void the form, one must clearly mark it as “VOID” and sign and date it. A new POLST form can then be completed to indicate any changes in treatment preferences. Regular reviews of the POLST are recommended, especially after significant health changes or transfers between care settings.

What should be done with the POLST form during patient transfers?

It is essential to send the POLST form with the patient whenever they are transferred or discharged from a healthcare facility. This ensures that all healthcare providers involved in the patient's care are aware of their treatment preferences. The form should remain accessible and visible to ensure that the patient’s wishes are respected at all times.

Document Attributes

Fact Name Details
Purpose of POLST The Provider Orders for Life-Sustaining Treatment (POLST) form is designed to communicate a patient's preferences regarding medical treatment in emergency situations.
Governing Law The POLST form in Hawaii is governed by the Hawaii Revised Statutes §327E-5.
Who Can Sign A POLST must be signed by a licensed Physician or Advanced Practice Registered Nurse (APRN) and the patient or their legally authorized representative.
HIPAA Compliance HIPAA allows for the disclosure of POLST forms to other healthcare professionals as necessary to ensure appropriate care.
Treatment Preferences Any section not completed on the POLST form implies full treatment for that section, ensuring that patient wishes are respected.
Transfer of Care The POLST form must accompany the patient whenever they are transferred or discharged from a healthcare facility.
Review Recommendations It is recommended to review the POLST periodically, especially when there is a significant change in health status or treatment preferences.
Modification of POLST A patient or their legally authorized representative can request changes to the POLST at any time, and the form can be voided by marking it clearly and signing it.
Comfort Measures Patients who choose "Comfort Measures Only" should be transferred to a setting that can provide adequate comfort if their needs cannot be met where they are.

Misconceptions

  • POLST is only for terminally ill patients. Many people believe that the POLST form is reserved solely for those who are at the end of life. In reality, it can be used by anyone with serious health conditions, regardless of their prognosis. This form helps ensure that a patient’s treatment preferences are respected at any stage of their illness.
  • Completing a POLST form is the same as creating a will. Some might think that a POLST is akin to a will, which deals with asset distribution after death. However, the POLST form specifically addresses medical treatment preferences while a person is still alive. It outlines what kind of medical interventions a patient wants or does not want in emergency situations.
  • A POLST form can be completed by anyone. It’s a common misconception that any individual can fill out a POLST form. In fact, it must be completed by a healthcare professional, such as a physician or an Advanced Practice Registered Nurse (APRN), based on the patient’s medical condition and preferences.
  • Once signed, a POLST form cannot be changed. Some people believe that the POLST form is set in stone once it is signed. This is not true. Patients or their legally authorized representatives can request changes to the POLST at any time, as long as they have the capacity to do so.
  • POLST forms are only valid in Hawaii. While the POLST form is specific to Hawaii, similar forms exist in other states. The key is that a POLST form is recognized across state lines in many cases, especially if it is signed by a licensed healthcare provider.
  • Having a POLST form means you don’t need to discuss your wishes with family. Some individuals think that filling out a POLST form eliminates the need for conversations with family members about their medical preferences. In truth, discussing these wishes with loved ones is crucial. It ensures that everyone understands the patient’s desires and can advocate for them if necessary.
  • POLST forms are only for older adults. There’s a misconception that only older adults should have a POLST form. However, anyone with serious medical conditions, regardless of age, can benefit from having a POLST. It’s about ensuring that treatment preferences are clear and respected, no matter the patient’s age.

Key takeaways

Understanding the Hawaii POLST form is crucial for ensuring that medical decisions align with a patient's preferences. Here are key takeaways regarding the completion and use of the form:

  • The POLST form must be filled out by a healthcare professional based on the patient's medical condition and preferences.
  • It is essential for the form to be signed by a physician or an Advanced Practice Registered Nurse (APRN) licensed in Hawaii, along with the patient or their legally authorized representative.
  • Any section left incomplete on the POLST form implies that full treatment is to be provided for that section.
  • Patients who select "Do Not Attempt Resuscitation" should not have a defibrillator used on them.
  • Comfort measures may require transfer to a different setting if they cannot be adequately provided in the current location.
  • Patients wishing to receive IV fluids should select either "Limited Interventions" or "Full Treatment."
  • A legally authorized representative may make decisions regarding artificial nutrition or hydration, but specific conditions must be met for a surrogate selected by consensus of interested persons to withhold or withdraw such care.
  • The POLST form should be reviewed periodically, especially when a patient is transferred between care settings or experiences significant health changes.
  • To modify or void a POLST form, draw a line through the sections and write "VOID," sign, and date the line. A new form should then be completed to reflect the changes.

These points can help ensure that the POLST form is used effectively and that patient wishes are respected in medical care.