Contact Us | Home

SEARCH

GO

Find POLST Paradigm information and forms for:


Developing a Program

Seek Endorsement of Your Developed Program

A POLST Paradigm Program can be endorsed by the National POLST Paradigm Intitiative Task Force. To be considered for endorsement simply complete two items: the Program Requirement Checklist and the POLST Paradigm Program Endorsement form below. Within six weeks the Task Force will review your information, endorse your program if criteria are met and provide feedback about your program. Please contact us if you have questions. Complete the following information describing your POLST Paradigm Program. Programs may be asked to update their information periodically.

If you are not seeking Task Force endorsement of your program please click here to fill out the information form.

 

Who may we contact for more information about a POLST Paradigm Program in your state or community?

Name:

Mailing Address:
(Address Line 1)
(Address Line 2)

City: State: Zip Code:
Phone: Fax: Email:

Name of state or community with a POLST Paradigm Program:

Describe the geographic area of your program:

Name of form or program that is being used:

Program Requirements

In order to be considered a POLST Paradigm Program, the Program must include these elements:

Possible POLST Paradigm Components Yes No Optional

1. The form constitutes a set of medical orders.

2. The process includes ongoing training of health care providers across the continuum of care about the goals of the program as well as the creation and use of the form.

3. Use of the form is recommended for persons who have advanced chronic progressive illness, those who might die in the next year or anyone wishing to further define their preferences of care.

4.The National POLST Paradigm Initiative Task Force strongly recommends that all POLST Paradigm programs require the signature of either the patient or the patient’s legal representative to make the form valid, as allowed by statute and regulations. The signature of the patient (or the patient’s legal representative if the patient lacks decision-making capacity) provides evidence that patients or their legal representatives agree with the orders on the form. In this respect, the requirement that patients or their legal representatives review and sign the form provides a safeguard for patients that the orders on the form accurately convey their preferences. Completion of the POLST form is voluntary, and the goal of such a form is to ensure that the patient receives the level of care desired.

5. The form requires a valid Physician (Nurse Practitioner or Physician Assistant accepted depending upon program) signature and date of signature.

6. The form may be used either to clarify a request for all medically indicated treatments including resuscitation or to limit medical interventions.

7. The form provides explicit direction about resuscitation status if the patient is pulseless and apneic.

8. The form also includes directions about other types of intervention that the patient may or may not want. For example, decisions about transport, ICU care, antibiotics, artificial nutrition, etc.

9. The form accompanies the patient, and is transferable and applicable across care settings (i.e. home, long term care, hospice, EMS, hospital).

10. The form is uniquely identifiable, standardized, with a uniform color within a state/region.
11. There is a plan for ongoing evaluation of the program and its implementation.

 

Describe the extent of use

What year did your program first use the POLST Paradigm form?

List the type of settings that this form or similar form is being used

Indicate the range of prevalence of use in each setting.

Can this form can be used for patients under 18 years of age?

Number distributed per month for your state or region

Number distributed per year for your state or community?

History of adopting the POLST. How and why did the POLST program get started in your community or state?

What barriers were faced and how were they removed or overcome?

What relevant state laws and/or regulations apply or control the use of your POLST form?

How does the use of the POLST form fit into the larger system of providing health care?

What policies are necessary at hospitals, nursing home, EMS, etc?

Who manages or oversees the program?

What type of training of health care professionals is provided for handling and honoring the form?

What training is provided to assure that health care professionals who discuss the choices offered on the POLST paradigm form are competent to conduct and facilitate these discussions and decisions with patients or their surrogates? Nurses and social workers throughout the state are trained to talk about end-of-life issues with patients and families.

What type of public and patient education is provided?

What CQI projects or research projects have been done and what outcomes have they demonstrated?

Optional Elements

The following issues may be handled by programs in different ways depending on state law and local preferences.

  1. Some programs may require patient/surrogate signature on the POLST form and some may not.
  2. Ideally, a surrogate should be able to make decisions about treatment choices for a patient without decision-making capacity, but states have varying laws regarding surrogates and decision making.
  3. Some states may recognize the form as the only out of hospital DNR form; in others there may be other means of DNR ID as well. Use of the form is always voluntary.
  4. Ideally, states would accept forms completed in other states (reciprocity).

back to top
"));