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Provider Orders for Life Sustaining Treatment (POLST)

This MontGuide explains POLST, a medical order indicating treatment preferences for a person who has a life-threatening illness. The document is signed by the patient and a Montana licensed physician, advanced practice registered nurse or physician assistant.

Last Updated: 11/20
by Marsha Goetting

What is a Montana POLST?

Provider Orders for Life Sustaining Treatment (POLST) is a medical order. You or your agent whom you have named in a health care power of attorney and your health care provider are the individuals who sign the document. The completed POLST establishes that you and your medical provider have discussed and you have indicated treatment preferences when you have a serious illness. You do not have to fill out a POLST document. The completion of a POLST is VOLUNTARY.

The POLST document should become a part of your medical records regardless of where you are being treated (at home, in an emergency room, hospital, nursing home, memory care unit or assisted living facility).

While the document was designed to be transferrable among settings, a new provider may ask you to complete another POLST. The new provider often “redocuments” to verify he/she had a discussion with you about your treatment preferences throughout your stay at this different facility during the latest stage of a serious illness. If you complete a POLST, all health care providers and family members should be aware of what you have stated in the document.

 

How did POLST become available in Montana?

Oregon was the first state to establish the POLST form. The development was in response to seriously ill patients who received medical treatments not consistent with their wishes. The Montana Board of Medical Examiners was approached about creating a POLST document for the state. With assistance from the Montana Department of Public Health and Human Services (DPHHS), POLST first became available in Montana during 2010. Since that time, the document has been revised twice, most recently in September of 2019.

If you completed a POLST form before September of 2019, you do not need to fill out a new one. Previous versions of the POLST forms remain valid until they are replaced by a new version. The most recent form is an 8.5 x 11-inch double-sided paper (terra green) and dated September, 2019.

POLST is now accepted or under development in 46 states. Participating states can be found at the national POLST website, www.polst.org. Each state has its own POLST requirements and reciprocity rules for forms. If you are going to stay in another state for an extended period, your Montana POLST may need to be redocumented on that state’s form.

 

My dad had a Comfort One and my mom had a DNR. Why can’t I do the same?

The Comfort One program has been eliminated from the Emergency Medical Services system in Montana. Comfort One has been replaced by POLST. Existing Comfort One documents and bracelets, however, will be honored by Emergency Medical Technicians (EMTs).

A do-not-resuscitate (DNR) is a directive from a licensed physician or advanced practice registered nurse indicating health care providers should not attempt cardiopulmonary resuscitation (CPR) if a patient’s heart or breathing stops. The state of Montana has replaced DNRs with a POLST.

 

I have a declaration (living will). Why do I need a POLST?

The Montana Terminally Ill Act enables an individual who is of sound mind and who is an adult (18 or more years of age) to make a declaration (living will). The declaration governs the withholding or withdrawing of life-sustaining treatment when a person is in a terminal condition. A declaration must be signed by the person executing it and by two witnesses. A declaration is not a medical order like the POLST document.

A Montanan can also designate another individual (designee) to make decisions about the withholding or withdrawing of life-sustaining treatment if he/she is unable to do so. For more information about a declaration, read the MSU Extension MontGuide, Montana Rights of the Terminally Ill Act (MT199202HR).

Montanans who want to provide additional details about their health care preferences are encouraged by health care providers and attorneys to have a Health Care Power of Attorney, https://store.msuextension.org/publications/FamilyFinancialManagement/EB0231ADA.pdf in addition to a POLST.

MSU Extension has partnered with several groups to provide an End of Life Worksheet; Health Care Power of Attorney (form); Declaration (living will form); and Additional Directions (form) for Montanans. Advance directive forms are also available from local hospitals and doctors. Attorneys can also write an advance directive or a health care power of attorney for you.

If you have several documents addressing your desires about medical treatment near the end of life, you should review all to ensure consistency among them. Contradictions among multiple forms and documents may result in confusion and limit a health care provider’s ability to make medical decisions on your behalf. Family members may also have disagreements about which document should have priority over another.

 

What preferences may I express on a POLST form?

Preferences for life sustaining treatment listed on the Montana POLST form are provided in Sections A-C.

Section A: Provides two choices for CPR. These orders apply only to the circumstances in which the person has no pulse and is not breathing.
YES CPR: Attempt Resuscitation
NO CPR: Do not Attempt Resuscitation (DNAR) and Allow Natural Death
 
Section B: Provides three categories of treatment options for medical interventions if the person has a pulse and is breathing.
Full Treatment-primary goal: To prolong life by all medically effective means: In addition to treatments described below in “Selective Treatment” and “Comfort-focused Treatment,” use intubation (insertion of a breathing tube in the trachea for mechanical ventilation), advanced airway interventions, mechanical ventilation, and cardioversion, as indicated. Transfer to hospital if indicated. Includes intensive care.
Selective Treatment-goal: To treat medical conditions while avoiding burdensome measures: In addition to treatment described below in “Comfort? focused Treatment,” use IV antibiotics and IV fluids, as indicated. Do not intubate. May use noninvasive positive airway pressure. Transfer to hospital if indicated. Avoid intensive care.
Comfort-focused Treatment-primary goal: To maximize comfort: Relieve pain and suffering with medication by any route, as needed; use oxygen, suctioning, and manual treatment of airway obstruction, if indicated. Do not use treatments listed in “Full Treatment” and “Selective Treatment” above, unless consistent with comfort goal. Do not transfer to hospital for life?sustaining treatment. Transfer only if comfort needs cannot be met in current location.
 
Section C: Provides the patient with four choices about artificially administered nutrition (if feasible, always offer food and water by mouth). Certain medical conditions may prevent intake of food and water, as they can worsen symptoms. If this applies, further discussion with and documentation by a healthcare provider is required.
Artificial nutrition by tube: long term/permanent, if indicated
Artificial nutrition by tube: short term/temporary only
No artificial nutrition by tube
No decision has been made

 

Section D: Provides boxes to indicate with whom the POLST form was discussed (patient, medical power of attorney agent, legal guardian or other). A place to indicate the relationship to the patient is also provided.

Last Section: This section has space for signatures of the following: Health Care Provider; Patient; Surrogate; Medical Power of Attorney Agent; and Legal Guardian. The signatures are mandatory. The provider (Montana licensed physician, advanced practice registered nurse, physician assistant) who signs the form confirms orders on the POLST form are consistent with the medical conditions and preferences of the patient.

 

Where can I get a POLST form and a POLST bracelet?

Almost all health care providers have copies of the terra green POLST forms and envelopes. A reduced-in-size sample of the POLST form appears at the end of this MontGuide. This is only a sample for reference. A Montanan should not fill out this form for submission to a health care provider. Most hospitals and doctors’ offices have the POLST form on the terra green paper. The form can be found at the Montana POLST website: www.polst.mt.gov

DPHHS has POLST bracelets and necklaces available for $20 each (address on page 4). When a person orders a bracelet or necklace, a copy of his/her POLST form is required. Only persons who have chosen “Do Not Resuscitate” on their POLST form should wear a POLST bracelet or necklace.

 

Where should a POLST form be kept?

The original of the terra green (light lime green) POLST form should be kept with the patient. A photocopy of the POLST form (on white paper) should accompany the patient when he/she is transferred from one health care facility to another. An example could be a person who is admitted to a hospital from a nursing home.

The Montana POLST Coalition has a recommendation for patients who have returned to their homes. Keep the POLST form in a green POLST envelope on the outside of the kitchen refrigerator so it is always visible.

You should inform family members or friends who are to be involved in decisions about your health care about the specific location of your original POLST and any POLST copies. They should also be aware of any other health care documents you have executed, such as an advance directive, health care power of attorney or declaration (living will). Having all medical documents in a folder or three-ring binder makes the materials easily accessible to family members.

 

When should I review my POLST form?

A POLST form should be reviewed periodically and specifically when:

  • The patient is transferred from one health care setting or care level to another.
  • There is substantial change in the patient’s health care status including previous wishes that conflict with medical recommendations.
  • The patient has a change in treatment preferences.

 

What if I want to modify or void my POLST?

A patient or health care agent can at any time void a POLST by executing a verbal or written advance directive or by completing a new POLST form. After a discussion with a health care provider, you can void the form by writing VOID on it. Your POLST document may also be stored in the provider’s electronic records, so be sure it is voided in the system. The most recently completed POLST form is the valid one. It supersedes all prior POLST forms.

 

Who can make medical decisions for me if I don’t have any type of health care document?

If you have not indicated a health care representative in some type of legal document [POLST form, health care power of attorney, advance care directive, declaration (living will)], Montana law provides that the authority to consent or to withhold consent for the administration of life-sustaining treatment may be exercised by the following individuals (in order of priority):

  1. The spouse of the individual.
  2. An adult child of the individual or, if there is more than one adult child, a majority of the adult children who are reasonably available for consultation.
  3. The parents of the individual.
  4. An adult sibling of the individual or, if there is more than one adult sibling, a majority of the adult siblings who are reasonably available for consultation.
  5. The nearest other adult relative of the individual by blood or adoption who is reasonably available for consultation.

 

Summary

A Montana POLST is a voluntary medical order for a person with a serious illness. A completed POLST form communicates to health care providers and family members an individual’s preferences about life sustaining treatments towards the end of life.

Family members or friends who may be faced with decisions about health care for a loved one should ask about the location of not only the original POLST, but also any other health care documents that have been completed [advance directive, health care power of attorney or declaration (living will)].

 

Further Information

Montana

Montana POLST
POLST forms and envelopes; bracelets and necklaces ($20 each)
Department of Public Health and Human Services (DPHHS)
EMS & Trauma System Section
P.O. Box 202951
Helena MT 59620
Phone: (406) 444-3895

 

Montana State University Extension MontGuides
(Montana Rights of the Terminally Ill Act, Montana End-of-Life Registry, Montana Health Care Power of Attorney):
These MontGuides are available free from your local MSU Extension office or MSU Extension Distribution Center:
P.O. Box 172040
Bozeman, MT 59717
Phone: (406) 994-3273

 

Montana Health Care Providers Consumers Guide
MHA – An Association of Montana Health Care Providers,
1720 Ninth Avenue
Helena, MT 59601
Phone: (406) 442-1911
Web site: www.mtha.org

 

National

 

 

National Hospice and Palliative Care Organization (search for hospice or palliative care, by clicking Find a Provider),
End of Life Care Publications
1731 King Street, Suite 100
Alexandria, VA 22314
Phone: (703) 837-1500
Web site: www.nhpco.org

 

National POLST Paradigm Task Force c/o Emmer Consulting, Inc.
208 1 Street NE
Washington, DC 20002

 

  • PREPARE for your care
    • Toolkit for Group Movie Events
    • Movie
    • Question Guide
    • Advance Directive

 

 

Acknowledgements

Representatives of the following professional organization have reviewed this POLST MontGuide:

Health Care Law Section, State Bar of Montana

 

Example of a POLST form for reference only:

Example of a POLST form for reference only.


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