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Blank Hawaii Polst Form

The Provider Orders for Life-Sustaining Treatment (POLST) form in Hawaii is a crucial document that outlines a patient's medical treatment preferences in the event of a medical emergency. It ensures that healthcare providers respect the individual's wishes regarding life-sustaining measures based on their current medical condition. Understanding how to properly utilize and implement this form can empower patients and their families to make informed decisions about end-of-life care.

Outline

The Hawaii Provider Orders for Life-Sustaining Treatment (POLST) form is an essential tool designed to ensure that individuals receive medical care aligned with their personal preferences, especially during critical health situations. This form outlines specific medical orders regarding resuscitation, medical interventions, and nutrition, providing clear guidance for healthcare professionals. It emphasizes the importance of dignity and respect in patient care, ensuring that each person's wishes are honored. The POLST form includes sections for cardiopulmonary resuscitation (CPR) preferences, medical interventions ranging from comfort measures to full treatment, and decisions about artificially administered nutrition. Additionally, it requires signatures from both a healthcare provider and the patient or their legally authorized representative, confirming that the orders reflect the patient's medical condition and desires. Healthcare providers must adhere to the directives outlined in the POLST form, which can be modified or revoked as the patient's health status or preferences change. Regular reviews of the POLST form are recommended to ensure it remains consistent with the patient's current wishes and medical condition.

Sample - Hawaii Polst Form

HIPAA PERMITS DISCLOSURE OF POLST TO OTHER HEALTH CARE PROFESSIONALS AS NECESSARY

PROVIDER ORDERS FOR LIFE-SUSTAINING TREATMENT (POLST) - HAWAI‘I

	FIRST follow these orders. THEN contact the			Paient’s Last Name
	paient’s provider. This Provider Order form is
	based on the person’s current medical condiion
	based on the person’s current medical condiion			First/Middle Name
	and wishes. Any secion not completed implies
	full treatment for that secion. Everyone shall be
	full treatment for that secion. Everyone shall be			Date of Birth	Date Form Prepared
	treated with dignity and respect.			Date of Birth	Date Form Prepared
	treated with dignity and respect.

A	CARDIOPULMONARY RESUSCITATION (CPR): Person has no pulse and is not breathing
A	Atempt Resuscitaion/CPR	Do Not Atempt Resuscitaion/DNAR (Allow Natural Death)
Check	(Secion B: Full Treatment required)
One	(Secion B: Full Treatment required)
One	If the paient has a pulse, then follow orders in B and C.
	If the paient has a pulse, then follow orders in B and C.
B	MEDICAL INTERVENTIONS:		Person has pulse and/or is breathing
B	Comfort Measures Only Use medicaion by any route, posiioning, wound care and other measures to relieve pain
Check	and suﬀering. Use oxygen, sucion and manual treatment of airway obstrucion as needed for comfort. TRANSFER IF COMFORT
One	needs cannot be met in current locaion.

Limited Addiional Intervenions Includes care described above. Use medical treatment, anibioics, and IV ﬂuids as indicated. Do not intubate. May use less invasive airway support (e.g. coninuous or bi-level posiive airway pressure). TRANSFER to hospital if indicated. Avoid intensive care.

Full Treatment Includes care described above. Use intubaion, advanced airway intervenions, mechanical venilaion, and deﬁbrillaion/cardioversion as indicated. TRANSFER to hospital if indicated. Includes intensive care.

Addiional Orders:

C	ARTIFICIALLY ADMINISTERED NUTRITION: Always offer food and liquid by mouth if feasible
C	(See Direcions on next page for informaion on nutriion & hydraion)			and desired.
Check	No ariﬁcial nutriion by tube.		Deﬁned trial period of ariﬁcial nutriion by tube.
One	Long-term ariﬁcial nutriion by tube.		Goal:


	Addiional Orders:
	Addiional Orders:
D	SIGNATURES AND SUMMARY OF MEDICAL CONDITION - Discussed with:
D	Paient or	Legally Authorized Representaive (LAR). If LAR is checked, you must check one of the boxes below:
	Paient or
Check
Check	Guardian	Agent designated in Power of Atorney for Healthcare		Paient-designated surrogate
One	Guardian	Agent designated in Power of Atorney for Healthcare		Paient-designated surrogate
One
	Surrogate selected by consensus of interested persons (Sign secion E)			Parent of a Minor

Signature of Provider (Physician/APRN licensed in the state of Hawai‘i.)

My signature below indicates to the best of my knowledge that these orders are consistent with the person’s medical condiion and preferences.

Print Provider Name	Provider Phone Number	Date

Provider Signature (required)	Provider License #

Signature of Paient or Legally Authorized Representaive

My signature below indicates that these orders/resuscitaive measures are consistent with my wishes or (if signed by LAR) the known wishes and/or in the best interests of the paient who is the subject of this form.

Signature (required)

Name (print)

Relaionship (write ‘self’ if paient)

Summary of Medical Condiion

Oﬃcial Use Only

SEND FORM WITH PERSON WHENEVER TRANSFERRED OR DISCHARGED

HIPAA PERMITS DISCLOSURE OF POLST TO OTHER HEALTH CARE PROFESSIONALS AS NECESSARY

Paient Name (last, ﬁrst, middle)

Date of Birth

Gender

M F

Patient’s Preferred Emergency Contact or Legally Authorized Representative

Name	Address		Phone Number

Health Care Professional Preparing Form	Preparer Title	Phone Number	Date Form Prepared

E	SURROGATE SELECTED BY CONSENSUS OF INTERESTED PERSONS
	(Legally Authorized Representaive as outlined in secion D)
	I make this declaraion under the penalty of false swearing to establish my authority to act as the legally authorized represen-
	taive for the paient named on this form. The paient has been determined by the primary physician to lack decisional

capacity and no health care agent or court appointed guardian or paient-designated surrogate has been appointed or the agent or guardian or designated surrogate is not reasonably available. The primary physician or the physician’s designee has made reasonable eﬀorts to locate as many interested persons as pracicable and has informed such persons of the paient's lack of capacity and that a surrogate decision-maker should be selected for the paient. As a result I have been selected to act as the paient’s surrogate decision-maker in accordance with Hawai‘i Revised Statutes §327E-5. I have read secion C below and understand the limitaions regarding decisions to withhold or to withdraw ariﬁcial hydraion and nutriion.

	Signature (required)	Name	Relaionship

Compleing POLST

DIRECTIONS FOR HEALTH CARE PROFESSIONAL

•Must be completed by health care professional based on paient preferences and medical indicaions.

•POLST must be signed by a Physician or Advanced Pracice Registered Nurse (APRN) licensed in the state of Hawai‘i and the paient or the paient’s legally authorized representaive to be valid. Verbal orders by providers are not acceptable.

•Use of original form is strongly encouraged. Photocopies and FAXes of signed POLST forms are legal and valid.

Using POLST

• Any incomplete secion of POLST implies full treatment for that secion. Secion A:

• No deﬁbrillator (including automated external deﬁbrillators) should be used on a person who has chosen “Do Not Atempt Resuscitaion.”

Secion B:

•When comfort cannot be achieved in the current seing, the person, including someone with “Comfort Measures Only,” should be transferred to a seing able to provide comfort (e.g., treatment of a hip fracture).

•IV medicaion to enhance comfort may be appropriate for a person who has chosen “Comfort Measures Only.”

•A person who desires IV ﬂuids should indicate “Limited Intervenions” or “Full Treatment.”

Secion C:

• A paient or a legally authorized representaive may make decisions regarding arficial nutriion or hydraion. However, a surrogate who has not been designated by the paient (surrogate selected by consensus of interested persons) may only make a decision to withhold or withdraw ariﬁcial nutriion and hydraion when the primary physician and a second independent physician cerify in the paient’s medical records that the provision or coninuaion of ariﬁcial nutriion or hydraion is merely prolonging the act of dying and the paient is highly unlikely to have any neurological response in the future. HRS §327E-5.

Reviewing POLST

It is recommended that POLST be reviewed periodically. Review is recommended when:

•The person is transferred from one care seing or care level to another, or

•There is a substanial change in the person’s health status, or

•The person’s treatment preferences change.

Modifying and Voiding POLST

•A person with capacity or, if lacking capacity the legally authorized representaive, can request a diﬀerent treatment plan and may revoke the POLST at any ime and in any manner that communicates an intenion as to this change.

•To void or modify a POLST form, draw a line through Secions A through E and write “VOID” in large leters on the original and all copies. Sign and date this line. Complete a new POLST form indicaing the modiﬁcaions.

•The paient’s provider may medically evaluate the paient and recommend new orders based on the paient’s current health status and goals of care.

Kōkua Mau – Hawai‘i Hospice and Palliaive Care Organizaion

Kōkua Mau is the lead agency for implementaion of POLST in Hawai‘i. Visit www.kokuamau.org/polst to download a copy

or ﬁnd more POLST informaion. This form has been adopted by the Department of Health July 2014

Kōkua Mau • PO Box 62155 • Honolulu HI 96839 • [email protected] • www.kokuamau.org

SEND FORM WITH PERSON WHENEVER TRANSFERRED OR DISCHARGED

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Form Information

Fact Name	Description
Purpose of POLST	The POLST form is designed to communicate a patient’s preferences for life-sustaining treatment based on their current medical condition.
Legal Basis	In Hawaii, the POLST form is governed by Hawai‘i Revised Statutes §327E, which outlines the use and authority of advance directives.
Completion Requirements	The form must be signed by a licensed physician or Advanced Practice Registered Nurse (APRN) in Hawaii, along with the patient or their legally authorized representative.
Treatment Preferences	Sections of the POLST form allow patients to specify their preferences for resuscitation, medical interventions, and nutrition.
HIPAA Compliance	The form complies with HIPAA regulations, allowing healthcare professionals to share POLST information as necessary for patient care.
Revocation	Patients or their legally authorized representatives can revoke or modify the POLST at any time, simply by communicating their intention.
Periodic Review	It is recommended that the POLST form be reviewed periodically, especially when a patient’s health status changes or they are transferred between care settings.
Use of Copies	While the original POLST form is encouraged, photocopies and faxed versions of signed forms are also considered valid and legal.

Detailed Guide for Filling Out Hawaii Polst

Filling out the Hawaii POLST form is a straightforward process that ensures a person's medical preferences are documented and communicated effectively. This form should be completed with care, as it reflects the individual's wishes regarding medical treatment in various situations. Follow these steps to fill out the form correctly.

Obtain the form: Get a copy of the Hawaii POLST form from a healthcare provider or download it from the Kōkua Mau website.
Fill in patient information: Write the patient's last name, first name, middle name, date of birth, and gender (M/F) at the top of the form.
Identify the emergency contact: Provide the name, address, and phone number of the patient's preferred emergency contact or legally authorized representative.
Complete Section A: Choose between "Attempt Resuscitation/CPR" or "Do Not Attempt Resuscitation/DNAR" based on the patient's wishes.
Complete Section B: Indicate the desired level of medical interventions if the patient has a pulse and/or is breathing. Options include "Comfort Measures Only," "Limited Additional Interventions," and "Full Treatment."
Complete Section C: Decide on the approach to artificially administered nutrition. Options include "No artificial nutrition by tube," "Defined trial period of artificial nutrition by tube," or "Long-term artificial nutrition by tube."
Discuss with the patient or representative: Ensure the patient or their legally authorized representative understands the form and agrees with the selections made.
Signatures: Obtain the signature of the healthcare provider (physician or APRN) and the patient or their legally authorized representative. Print their names and relationships where required.
Complete additional orders: If there are any specific medical conditions or additional orders, document them clearly.
Review the form: Double-check all sections to ensure accuracy and completeness before finalizing.
Send the form: Make sure to send the completed form with the patient whenever they are transferred or discharged.

After filling out the form, it is essential to keep it updated. Changes in health status or treatment preferences should prompt a review of the POLST. This ensures that the medical orders reflect the patient's current wishes and needs.

Obtain Answers on Hawaii Polst

What is the Hawaii POLST form?

The Hawaii Provider Orders for Life-Sustaining Treatment (POLST) form is a medical document. It outlines a person's preferences for medical treatment in emergency situations. This form is based on the individual’s current medical condition and wishes. It helps ensure that healthcare providers follow the person's desires regarding life-sustaining measures.
Who should complete the POLST form?

A healthcare professional, such as a physician or an Advanced Practice Registered Nurse (APRN), must complete the POLST form. They will base the orders on the patient's medical preferences and conditions. The patient or their legally authorized representative must also sign the form for it to be valid.
What happens if a section of the POLST form is not completed?

If any section of the POLST form is left blank, it implies that the person desires full treatment for that section. This means that healthcare providers will take all necessary measures unless specified otherwise.
Can the POLST form be modified or revoked?

Yes, a person with capacity, or their legally authorized representative, can request changes to the treatment plan at any time. To modify or void the POLST form, simply draw a line through the relevant sections and write "VOID" on the original and all copies. Then, sign and date this change and complete a new POLST form with the desired modifications.
What should be done with the POLST form during transfers?

The POLST form must be sent with the patient whenever they are transferred or discharged from a healthcare facility. This ensures that all healthcare professionals involved in the patient's care are aware of their treatment preferences.
How often should the POLST form be reviewed?

It is recommended to review the POLST form periodically. A review is especially important when the person is transferred to a different care setting, experiences a significant change in health status, or if their treatment preferences change.
What if the patient cannot make decisions about their care?

If a patient lacks decisional capacity, a legally authorized representative can make decisions on their behalf. This representative may be a designated agent, a guardian, or a surrogate chosen by a consensus of interested persons. They must act in the best interest of the patient.
Where can I find more information about the POLST form?

For additional details about the POLST form, you can visit the Kōkua Mau website at www.kokuamau.org/polst. This site provides resources and downloadable copies of the POLST form.

Common mistakes

Filling out the Hawaii POLST form is a crucial step in ensuring that a person's healthcare wishes are honored. However, many individuals make mistakes that can lead to confusion or unintended consequences. One common error is failing to complete all sections of the form. Each section is designed to capture specific preferences regarding medical interventions. If a section is left blank, it is interpreted as a desire for full treatment in that area. This can be particularly problematic if the individual has specific wishes that are not clearly expressed.

Another frequent mistake involves misunderstanding the choices regarding cardiopulmonary resuscitation (CPR). Some people may check the "Do Not Attempt Resuscitation" option without fully understanding its implications. This decision should reflect a clear understanding of the individual’s wishes and medical condition. It is essential to discuss this choice with healthcare providers to ensure that it aligns with the person’s values and desires.

Additionally, individuals often overlook the importance of signatures on the POLST form. Both the healthcare provider and the patient or their legally authorized representative must sign the document for it to be valid. Without these signatures, the form may not be honored by healthcare professionals, potentially leading to unwanted treatments or interventions.

Another area of concern is the selection of a surrogate decision-maker. Some individuals might not fully understand the implications of choosing a surrogate selected by consensus of interested persons. This choice can lead to disputes among family members or caregivers about what the individual would have wanted. It’s vital to have clear communication and documentation regarding who is authorized to make decisions on behalf of the person.

Moreover, failing to periodically review the POLST form can result in outdated preferences being followed. As a person's health status changes, so too might their treatment preferences. Regular reviews ensure that the form accurately reflects the individual’s current wishes and medical condition.

Another mistake is neglecting to provide detailed information about the patient's medical condition. The summary section should clearly outline the individual's health status, as this information is crucial for healthcare providers when making treatment decisions. A vague or incomplete summary can lead to misunderstandings about the appropriate level of care.

Lastly, individuals sometimes assume that any healthcare professional can complete the POLST form. However, it must be filled out by a licensed physician or Advanced Practice Registered Nurse (APRN) in Hawaii. Ensuring that the form is completed by the appropriate professional is essential for its validity and effectiveness in guiding treatment decisions.

Documents used along the form

The Hawaii Physician Orders for Life-Sustaining Treatment (POLST) form is a crucial document for ensuring that a person's healthcare preferences are honored, particularly in emergency situations. However, it often works in conjunction with several other important forms and documents that can provide additional clarity and guidance regarding a person's medical wishes. Below is a list of commonly used documents alongside the POLST form, each serving a unique purpose.

Advance Healthcare Directive: This document allows individuals to specify their healthcare preferences and appoint a healthcare agent to make decisions on their behalf if they become unable to do so. It covers a range of medical treatments and interventions, ensuring that personal values and wishes are respected.
Living Will: A living will is a type of advance directive that focuses specifically on end-of-life care. It outlines the medical treatments an individual does or does not want if they are unable to communicate their wishes, particularly in situations like terminal illness or severe incapacitation.
Durable Power of Attorney for Healthcare: This legal document designates a specific person to make healthcare decisions on behalf of the individual if they are unable to do so themselves. It empowers the appointed agent to act in the best interest of the individual based on their known preferences.
Do Not Resuscitate (DNR) Order: A DNR order is a specific request to medical professionals not to perform cardiopulmonary resuscitation (CPR) in the event of cardiac arrest. This document is often used in conjunction with the POLST form to clarify resuscitation preferences.
Healthcare Proxy: Similar to a durable power of attorney, a healthcare proxy allows an individual to appoint someone to make healthcare decisions for them. This document is particularly useful if the individual becomes incapacitated and cannot express their wishes.
Patient Information and Medical History Form: This form provides healthcare providers with essential information about a patient’s medical history, current medications, allergies, and other relevant health details. It ensures that medical professionals have the necessary context to make informed decisions about care.

Understanding these documents and their roles can empower individuals to make informed decisions about their healthcare. By utilizing the POLST form alongside these other forms, patients can create a comprehensive plan that reflects their values and preferences, ensuring that their wishes are honored throughout their medical care journey.

Similar forms

The Hawaii POLST (Provider Orders for Life-Sustaining Treatment) form is designed to communicate a patient's preferences regarding medical treatment in emergency situations. Several other documents serve similar purposes in guiding healthcare decisions. Below is a list of seven documents that share similarities with the Hawaii POLST form:

Advance Directive: This document allows individuals to outline their preferences for medical treatment in advance, particularly when they become unable to communicate those wishes. Like the POLST, it emphasizes patient autonomy and dignity.
Living Will: A living will is a type of advance directive that specifically details the types of medical treatment a person wishes or does not wish to receive at the end of life. Both documents aim to respect the patient’s choices.
Durable Power of Attorney for Healthcare: This document designates a specific individual to make healthcare decisions on behalf of the patient if they are unable to do so. Similar to POLST, it ensures that a trusted person can advocate for the patient’s wishes.
Do Not Resuscitate (DNR) Order: A DNR order specifically instructs healthcare providers not to perform CPR in the event of cardiac arrest. Like POLST, it is a medical order that conveys the patient's wishes regarding resuscitation.
Medical Orders for Life-Sustaining Treatment (MOLST): Similar to POLST, MOLST is a medical order form that outlines a patient's preferences for life-sustaining treatment, ensuring that those preferences are honored in various healthcare settings.
Healthcare Proxy: This document allows individuals to appoint someone to make healthcare decisions on their behalf. It parallels the POLST form in that both emphasize the importance of having someone advocate for the patient's wishes.
Patient Care Preferences: This document outlines a patient's specific care preferences and wishes regarding treatment options, similar to the POLST form, which captures detailed instructions for healthcare providers.

Dos and Don'ts

When filling out the Hawaii POLST form, it's important to ensure that the process is done correctly to reflect the patient's wishes and medical needs. Here are nine guidelines to follow:

Do ensure that the form is completed by a qualified healthcare professional.
Do clearly discuss the patient's preferences regarding life-sustaining treatment with them or their legally authorized representative.
Do sign the form only if you are a licensed physician or Advanced Practice Registered Nurse (APRN) in Hawaii.
Do review the POLST form periodically, especially after a significant change in health status.
Do provide a copy of the POLST form to the patient and ensure it accompanies them during transfers or discharges.

Don't leave any section of the form incomplete, as this implies full treatment for that section.
Don't use verbal orders; all instructions must be written and signed on the form.
Don't assume that a surrogate can make decisions about artificial nutrition without proper designation and medical certification.
Don't forget to update the POLST form if the patient’s treatment preferences change or if they are transferred to a different care setting.

Following these guidelines can help ensure that the POLST form accurately represents the patient’s wishes and provides clear instructions for their care. It's a crucial step in honoring the dignity and respect that every individual deserves.

Misconceptions

There are many misunderstandings surrounding the Hawaii Provider Orders for Life-Sustaining Treatment (POLST) form. Here are six common misconceptions, along with clarifications to help you better understand this important document.

POLST is the same as a living will. While both documents express a person's wishes regarding medical treatment, a POLST form is a medical order signed by a physician, whereas a living will is not. POLST is intended for individuals with serious illnesses or those who may be nearing the end of life.
Only elderly people need a POLST form. This is not true. Anyone with a serious health condition or who wants to ensure their treatment preferences are respected can benefit from having a POLST form, regardless of age.
POLST is legally binding. Yes, once signed by a physician and the patient or their legally authorized representative, the POLST form is a legally binding medical order that healthcare providers must follow.
Completing a POLST form means giving up all medical treatment. Not at all. The POLST form allows individuals to specify their preferences for various levels of treatment. Patients can choose full treatment, limited interventions, or comfort measures only, based on their personal wishes.
Healthcare providers can ignore a POLST form. This is a misconception. Healthcare providers are legally required to follow the instructions outlined in a valid POLST form, as long as it has been completed correctly and signed.
Once completed, a POLST form cannot be changed. In reality, a POLST form can be modified or revoked at any time by the patient or their legally authorized representative. If changes are needed, the old form should be voided, and a new one completed.

Understanding these misconceptions can help individuals make informed decisions about their healthcare preferences and ensure that their wishes are respected. Always consult with healthcare professionals for guidance on completing and using a POLST form effectively.

Key takeaways

Filling out and using the Hawaii POLST form is a crucial step in ensuring that medical care aligns with a person's wishes. Here are some key takeaways to keep in mind:

Understand the Purpose: The POLST form is designed to communicate a person’s medical preferences, especially in emergency situations. It translates their wishes into actionable medical orders.
Complete Sections Carefully: Each section of the form must be filled out thoughtfully. If any section is left incomplete, it implies full treatment for that section.
Involve Healthcare Professionals: A physician or an Advanced Practice Registered Nurse (APRN) must sign the form for it to be valid. Verbal orders are not accepted.
Review Regularly: It’s recommended to review the POLST form periodically, especially after a significant change in health status or when transferring care settings.
Transfer with the Patient: Always send the POLST form with the person whenever they are transferred or discharged from a healthcare facility. This ensures that their wishes are respected at all times.
Modification is Possible: If circumstances change, the patient or their legally authorized representative can modify or revoke the POLST at any time. Clear communication of this intention is essential.
Consult Kōkua Mau: For additional guidance, Kōkua Mau is the lead agency for implementing POLST in Hawaii. Their website offers resources and further information about the form.

By keeping these takeaways in mind, individuals and families can better navigate the complexities of medical care preferences in Hawaii.