POLST Protocols

Mountainview Hospital

Purpose:  A recent change in Oregon law requires that the signer of a POLST form submit a copy of the form to the Oregon POLST Registry in order to maximize the chance that the patient’s wishes are carried out in any subsequent care setting.  EMS and emergency departments can access the POLST registry when a patient’s original POLST form is unavailable or cannot be located (see Emergent Requests for Care at the Scene by Emergency Medical Services

(EMS) and Hospital Emergency Departments (ED) below).

Who should have the opportunity to have a POLST?

• Anyone with advanced progressive illness or frailty

• Any hospice patient

POLST forms:  The most recent version (currently June 2009) of the POLST form should be used in all Mountain View Hospital facilities in order to ensure capture of the correct data for submission to the registry.  In general, the form is updated every two years.

Inpatient completion of a POLST form:

1. The POLST form is completed and signed by the attending physician following a discussion of the patient’s wishes for life-sustaining treatments with the patient and/or family members.  The POLST form should be completed in its entirety whenever possible.  At a minimum for submission to the registry, a valid POLST form must contain the following:
• Full name (first, MI, last)
• Date of birth
• A selection from section A (resuscitate or do not resuscitate)
• Professional signature
• Date signed
2. The completed POLST form is submitted to the discharge planner or ward clerk with the chart.  The ward clerk checks to make sure the POLST form is complete with the above items, and completes any missing demographic data from the face sheet.
3. The patient (or representative family member if the patient is unable) should have the opportunity to sign the back of the form, indicating that it reflects their wishes regarding life-sustaining treatment.  If unsigned initially, the form can be reviewed with the patient and/or family by nursing and then signed.
4. If, for some reason, the patient chooses NOT to have their POLST orders submitted to the registry, the box on the back of the form should be marked and the form will not be submitted.
5. Once correct and complete, the original POLST form is photocopied by the discharge planner or ward clerk.  The original remains at the front of the chart and will go with the patient at discharge or transfer to another facility.  The copied form is submitted by fax to the Oregon POLST registry with a cover page to indicate the source of the transmission.  The date of submission is recorded on the back of the POLST form.  A copy of the form is also placed under the History and Physical section of the chart to be filed in the permanent medical record.
6. When the HIM department abstracts the medical record, if the original POLST form is still in the record upon discharge, the abstracter will follow the above procedure and mail the original form to the patient or discharge facility.
7. Any questions will be directed to the discharge planner.

Transfer to Hospice:

            Patients changing from inpatient to hospice are currently required to have an up-to-date POLST form completed.  If a POLST form has already been completed but not submitted to the registry, the hospice nurse or ward clerk will ensure that the above five required elements are complete and submit the form to the registry.  If no previous POLST form has been completed, then the protocol above should be completed at or before the time of transfer or discharge.

Patients being discharged to Assisted Living or Nursing Home:

            Assisted living and nursing home facilities may require an up-to-date POLST form on their residents.  In order to ensure timely and correct submission to the POLST registry, the POLST form should be completed prior to discharge to one of these facilities and the form submitted according to the above protocol.

Accessing POLST Forms via the POLST Registry

POLST form Requests by Hospitals – Acute Care Units and ICUs

Acute Care Units and ICUs may request a POLST form by calling the Registry Office tollfree: 1‐877‐367‐7657. The Registry office is staffed 8am to 5pm Monday through Friday, however, if you call the Registry office after hours and need immediate access to POLST orders, you may press “0” to be transferred to the Emergency Communications Center (ECC) at OHSU. 24 hour access to POLST orders via the ECC is only available to hospital units. It is important for hospital units to note that by rule, emergent requests for POLST forms can only be sent to confirmed fax numbers. In order to assure compliance, at this time, the Registry office & ECC can only fax POLST forms to the requesting hospital’s Emergency Department. If a unit other than the Emergency Department is requesting the form, it is that unit’s responsibility to coordinate with its Emergency Department to obtain the faxed POLST form copy.

Emergent Requests for Care at the Scene by Emergency Medical Services (EMS) and Hospital Emergency Departments (ED)

EMS and hospital EDs can access POLST forms at the scene when POLST orders will impact the care provided to the patient, specifically orders for section (A) cardiopulmonary resuscitation (CPR), and section (B) medical interventions including use of oxygen, airway obstruction interventions, intubation, IV fluids, and cardioversion. Emergent retrieval of POLST orders are obtained through the Emergency Communications Center. This number is available upon request from Jenny Cook, Registry Coordinator at 503‐494‐1230, or at polstreg@ohsu.edu The ECC specialists can provide Section A and B orders, the date on which the POLST form was signed, and the POLST Registry ID number over the phone. The staff members are not medical providers, and cannot offer interpretation of POLST orders.

Madras Medical Group

MMG Protocol for Physician Orders for Life-Sustaining Treatment (POLST)

Purpose:  A recent change in Oregon law requires that the signer of a POLST form submit a copy of the form to the Oregon POLST Registry in order to maximize the chance that the patient’s wishes are carried out in any subsequent care setting.  EMS and emergency departments can access the POLST registry when a patient’s original POLST form is unavailable or cannot be located (see Emergent Requests for Care at the Scene by Emergency Medical Services

(EMS) and Hospital Emergency Departments (ED) below).

Who should have the opportunity to have a POLST?

• Anyone with advanced progressive illness or frailty

• Any hospice patient

POLST forms:  The most recent version (currently June 2009) of the POLST form should be used in order to ensure capture of the correct data for submission to the registry.  In general, the form is updated every two years.

Completion of a POLST form:

1. The POLST form is completed and signed by the provider following a discussion of the patient’s wishes for life-sustaining treatments with the patient and/or family members.  The POLST form should be completed in its entirety whenever possible.  At a minimum for submission to the registry, a valid POLST form must contain the following:
• Full name (first, MI, last)
• Date of birth
• A selection from section A (resuscitate or do not resuscitate)
• Professional signature
• Date signed
2. The completed POLST form is then given to the nurse (or medical assistant) with the chart.  The nurse checks to make sure the POLST form is complete with the above items, and completes any missing demographic data from the demographic sheet in the chart.
3. The patient (or representative family member if the patient is unable) should have the opportunity to sign the back of the form, indicating that it reflects their wishes regarding life-sustaining treatment.
4. If, for some reason, the patient chooses NOT to have their POLST orders submitted to the registry, the box on the back of the form should be marked and the form will not be submitted.
5. Once correct and complete, the original POLST form is photocopied by the nurse.  The copied form is submitted by fax or mail to the Oregon POLST registry with a cover page to indicate the source of the transmission.  The date of submission is recorded on the back of the POLST form.
6. The copied POLST form will be filed by medical records in the very back of the Correspondence section of the chart
7. The original POLST form goes home with the patient.
8. If medical records finds a completed original POLST form with the chart, the above protocol will be completed and the patient notified to come pick up the original form or have it mailed to them.