POLSTPhysician Orders for

Life-Sustaining TreatmentTraining

Contra Costa EMS AgencyPolicy 20

Change Effective 1/1/2009

POLSTPhysician Orders for Life-

Sustaining Treatment Training Objectives

• Define POLST and how the POLST form will be used in the prehospital setting in CCC.

• Determine what treatment to perform when Section A or B of the POLST form are marked.

• Identify that Section C is not applicable to the prehospital setting.

• Identify when a POLST form is valid.

What is POLST?• A form mandated by passage of

California Assembly Bill 3000 this past year

• Intended to aid in communication of patient’s treatment wishes (in form of a physician order)

• An alternative to the DNR order form with more complex treatment options for patients who are not in cardiac arrest

What is POLST?

• Primarily intended as a communication tool between nursing homes, hospices and hospitals.

• The form is not ideal for EMS (we are in the middle). Our EMS policies will continue to dictate care and interpretation of the form when the patient is in our hands.

In a Nutshell….• Front side of form has parts A through D.

– A and B are applicable to EMS– C is only applicable to facilities– D is signature section

• Back side has instructions for use. However, EMS care is dictated by our policy, not by the statements on the back side of the form.

• Original is supposed to be printed on bright pink paper, but photocopies and faxes are acceptable.

If POLST Form is Presented….1. Make sure patient is identified correctly

at the top of the form

2. Check Section D for signatures - to be valid, form must have signature of physician and patient (or other decision-maker)

3. If patient has no pulse and is not breathing, follow section A (to either resuscitate or not) – just like DNR forms

Top of Form andSection A: Cardiopulmonary Resuscitation

Should be followed just like DNR Form

Section B – Medical Interventions:

EMS Transport

4. For use when patient has a pulse and/or is breathing:

– For EMS purposes, information concerning patient transfer should be disregarded (“do not transfer” advisories). This is not intended as a “treat and release” authorization.

– Follow EMS Policy 10 if patient or family declines treatment/transport.

Section B – Medical Interventions

EMS Care

5. The only checkboxes which change EMS care are the “Comfort Measures Only” or “Limited Additional Interventions” boxes (first and second boxes):

– Only one box in Section B is supposed to be checked, but if either of first two boxes are checked, do not intubate.

Section B

Follow EMS Policy 10 for transport issues (not this form).

Do not intubate if either of the top two boxes are checked.

If Full Treatment checked, proceed with usual EMS care. Contact base if any questions.

Transfer directives are for facilities only. Follow EMS policy 10 if patient or family declines treatment or transport.

Section B Issues

• Any questions about appropriateness of other treatment can be discussed with base hospital if needed.

Section C

Not for Prehospital Use

Other Issues• DNR forms are still valid. If patient has

both, utilize form with the latest date.• If section A incomplete, full treatment

should be done.• If section B incomplete (no box

checked), full treatment should be done• If section D signatures of physician and

patient are not complete, full treatment should be done.

• If a DNR or POLST form is presented, but relatives on scene object to the order or the validity of the form is in question, full treatment should be done.