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Developing a Program

Sharing Information About Your Program

Sharing information about your program helps colleagues develop a similar program, improves task force understanding, and helps you gain insight from others. Please complete the following information describing your POLST Paradigm Program. Programs may be asked to update their information periodically.

If you are also seeking Task Force endorsement of your program please click here.

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:

Please review the Possible POLST Paradigm Form Components and
check yes, no, or optional to describe your current form.

Possible POLST Paradigm Components Yes No Optional
1. Form has a uniform, standardized color.
2. Decisions reflected in the form are medical orders that must be followed by emergency personnel in the field and emergency rooms.
3. The form accompanies the patient across care settings\
4. CPR/DNR section
5. Levels of interventions (3)
6. Levels of interventions (4)
7. Feeding tube
8. Antibiotics
9. Basis for orders
10. Person completing form
11. Physician/NP/PA signature
12. Physician/NP/PA name & office number
13. Patient/Legal agent signature
14. Designation of legal agent name and number
15. Space for review
16. Statement about leeway (Is the patient’s surrogate provided authority to interpret the goals and preferences at the time decisions are made?)

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?

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