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Video 3: How the POLST Form is Completed

How do I work with the doctor or nurse practitioner to complete the POLST form?

Because the POLST form is a medical order sheet, only the doctor or nurse practitioner may fill out the form. The form becomes a legal document and is active only after it is signed both by the doctor or nurse practitioner and by the decision maker. Verbal consent is allowed if the decision maker is unable to sign, or if the consent is obtained over the phone.

After discussing the diagnosis and prognosis with the doctor or nurse practitioner, you are now ready to help complete the POLST form.

Section A asks about personal goals of care. What personal goals and wishes are important to the patient during the time that remains in his or her life?

In this section, depending on the patient’s personal goals, the doctor may write things such as:

 “To return home to live independently”

Or

 “To live long enough to attend an upcoming family event or holiday”

 “To live as long as possible”

 Or

 “To die a peaceful death without pain or discomfort”

The remaining sections of the form are the actual medical orders and should support the personal goals of care established in Section A.

Section B asks about scope of care: Should the team focus on using all interventions to sustain life, use some middle of the road interventions and try to avoid hospitalizations, or focus only on comfort during the remaining period of life.

In this section, the doctor or practitioner may check off one of the three boxes.

  1. The first is Full treatment efforts to sustain life. If this box is checked, then all medically appropriate interventions will be offered, including transferring to a hospital setting, intensive care and even surgery if appropriate.
  2. The second box is Limited Treatment. This means that the medical team will try to avoid aggressive interventions such as intensive care and surgery.Under the limited treatment option, there is a question about returning to the hospital. The patient or decision maker may request to return to the hospital for care if needed in the future, or remain in the current setting, such as in the home or in the nursing facility.This decision should be discussed in detail with the doctor or practitioner, who should offer guidance as to whether returning to the hospital will help achieve the personal goals of care.
  3. The third box in this section is Symptom Treatment Only, which focuses only on comfort care. If this box is checked, only those interventions that provide comfort will be offered. And the patient will return to the hospital only if the symptoms cannot be managed in the current location.

Section C asks about the use of artificial nutrition and hydration during the final phase of life. When discussing nutrition and hydration with the doctor or practitioner, be sure to focus on whether or not these interventions will help achieve the personal goals established in Section A.

Section D asks about what the medical team should do when the patient dies — when the patient stops breathing or when the heart stops.

There is a common misunderstanding about just how effective CPR really is. Most of the time, sadly, CPR does not work, and it rarely works for older, frail adults with multiple medical problems.

The heart can sometimes be restarted if there is a primary cardiac problem such as an abnormal rhythm or heart failure. But if the heart stops because something outside the heart is making it stop, such as a lung problem, kidney problem, dementia or cancer syndrome, the medical team will likely not be able to restart the heart. Please be sure to ask the doctor or practitioner for his or her opinion about the chances of surviving CPR.

It’s important to know that CPR will be attempted in all patients who do not have a Do Not Resuscitate order on the POLST form.

Section E is reserved for those patients who are able to discuss their own POLST form with the doctor or nurse practitioner. It asks the patient if it is OK for his or her surrogate decision maker to change the POLST form orders after consulting with the doctors and in keeping with the patient’s overall goals.

If you are completing a POLST form for someone else and you are the decision maker for that person, this section should be left blank. If the POLST form is being completed for you, you may want to discuss this section in more detail with your doctor.

The final section is for signatures. The NJ POLST form will be active and legal only after it is signed by either the doctor or nurse practitioner and by the decision maker.

Where is the POLST form completed?

The POLST form may be completed for a patient in any medical setting. This could be a doctor’s office, in the hospital, nursing facility or even in the patient’s own home. Once the form is completed and signed, the original green POLST form stays with the patient, and copies are placed in the medical record.

4Step iCare Plan

An Individualized End of Life Care Plan

Our 4Step iCare Plan is a simple, 4-step approach that helps patients, families, and healthcare providers navigate through challenging medical decisions.
Learn more with our video series and helpful tools

Get Involved!

 As an agent of change. Join the Goals of Care Coalition of New Jersey to help improve end of life care for patients and families.
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GOCC Resources:

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NJ POLST Form Videos and Documents
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NJ POLST Form Videos and Documents

Programs

Programs

Blogs

GOCC Resources:

wtfdivi014-url4
NJ POLST Form Videos and Documents
wtfdivi014-url4
NJ POLST Form Videos and Documents

Programs

Programs

Programs