■ HIPAA PERMITS DISCLOSURE OF POLST TO HEALTH CARE PROFESSIONALS AS NECESSARY FOR TREATMENT • VERSION REVISED SEPTEMBER 2022 ■
State of Illinois
Department of Public Health
IDPH UNIFORM PRACTITIONER ORDER FOR
LIFE-SUSTAINING TREATMENT (POLST) FORM
For patients: Use of this form is completely voluntary. If desired, have someone you trust with you when discussing a POLST form with a health care
professional. For health care providers: Complete this form only after a conversation with the patient or the patient’s representative. The POLST decision-
making process is for patients who are at risk for a life-threatening clinical event because they have a serious life-limiting medical condition, which may
include advanced frailty. With significant change in condition, new orders may need to be written.
PATIENT INFORMATION. For patients: Use of this form is completely voluntary.
Patient Last Name
Patient First Name
MI
Date of Birth (mm/dd/yyyy)
Address (street/city/state/ZIP code)
A
Required
to Select
One
ORDERS FOR PATIENT IN CARDIAC ARREST. Follow if patient has NO pulse.
YES CPR: Attempt cardiopulmonary resuscitation (CPR). Utilize all
indicated modalities per standard medical protocol. (Requires
choosing Full Treatment in Section B.)
NO CPR: Do Not Attempt Resuscitation (DNAR).
B
Section
may be
Left
Blank
ORDERS FOR PATIENT NOT IN CARDIAC ARREST. Follow if patient has a pulse. Maximizing comfort is a goal regardless of which treatment
option is selected. (When no option selected, follow Full Treatment.)
Full Treatment: Primary goal is attempting to prevent cardiac arrest by using all indicated treatments. Utilize intubation, mechanical
ventilation, cardioversion, and all other treatments as indicated.
Selective Treatment: Primary goal is treating medical conditions with limited medical measures. Do not intubate or use invasive
mechanical ventilation. May use non-invasive forms of positive airway pressure, including CPAP and BiPAP. May use IV fluids, antibiotics,
vasopressors, and antiarrhythmics as indicated. Transfer to the hospital if indicated.
Comfort-Focused Treatment: Primary goal is maximizing comfort through symptom management. Allow natural death. Use medication
by any route as needed. Use oxygen, suctioning and manual treatment of airway obstruction. Do not use treatments listed in Full and
Selective Treatment unless consistent with comfort goal. Transfer to hospital only if comfort cannot be achieved in current setting.
C
Section
may be
Left
Blank
Additional Orders or Instructions. These orders are in addition to those above (e.g., withhold blood products; no dialysis). [EMS protocols
may limit emergency responder ability to act on orders in this section.]
D
Section
may be
Left
Blank
ORDERS FOR MEDICALLY ADMINISTERED NUTRITION. Offer food by mouth if tolerated. (When no selection made, provide standard of care.)
Provide artificial nutrition and hydration by any means, including new or existing surgically-placed tubes.
Trial period for artificial nutrition and hydration but NO surgically-placed tubes.
No artificial nutrition or hydration desired.
E
Required
Signature of Patient or Legal Representative. (eSigned documents are valid.)
X Printed Name (required)
Date
Signature (required) I have discussed treatment options and goals for care with a health care professional. If signing as legal representative,
to the best of my knowledge and belief, the treatments selected are consistent with the patient’s preferences.
X
Relationship of Signee to Patient:
Patient
Parent of minor
Agent under Power of
Attorney for Health Care
Health care surrogate decision maker
(See Page 2 for priority list)
F
Required
Qualified Health Care Practitioner. Physician, licensed resident (second year or higher), advanced practice nurse, or physician assistant.
(eSigned documents are valid.)
X Printed Authorized Practitioner Name (required)
Phone
___________________
Signature of Authorized Practitioner (required) To the best
of my knowledge and belief, these orders are consistent with
the patient’s medical condition and preferences.
X
Date (required)
■ HIPAA PERMITS DISCLOSURE OF POLST TO HEALTH CARE PROFESSIONALS AS NECESSARY FOR TREATMENT • VERSION REVISED SEPTEMBER 2022 ■
**THIS PAGE IS OPTIONAL – use for informational purposes**
Patient Last Name
Patient First Name
MI
Use of the Illinois Department of Public Health (IDPH) Practitioner Orders for Life-Sustaining Treatment (POLST) Form
is always voluntary. This order records a patient’s wishes for medical treatment in their current state of health. The patient or patient
representative and a health care provider should reassess and discuss interventions regularly to ensure treatments are meeting patient’s
care goals. This form can be changed to reflect new wishes at any time.
No form can address all the medical treatment decisions that may need to be made. The Power of Attorney for Health Care Advance
Directive (POAHC) is recommended for all capable adults, regardless of their health status. A POAHC allows a person to document, in
detail, future health care instructions and name a Legal Representative to speak on their behalf if they are unable to speak for
themselves.
Advance Directives available for patient at time of this form completion
Power of Attorney for Health Care
Living Will Declaration
Declaration for Mental Health Treatment
None Available
Health Care Professional Information
Preparer Name
Phone Number
Preparer Title
Date Prepared
Completing the IDPH POLST Form
• The completion of a POLST form is always voluntary, cannot be mandated, and may be changed at any time.
• A POLST should reflect current preferences of persons completing the POLST Form; encourage completion of a POAHC.
• Verbal/phone consent by the patient or legal representative are acceptable.
• Verbal/phone orders are acceptable with follow-up signature by authorized practitioner in accordance with facility/community policy.
• Use of the original form is encouraged. Digital copies and photocopies, including faxes, on ANY COLOR paper are legal and valid.
• Forms with eSignatures are legal and valid.
• A qualified health care practitioner may be licensed in Illinois or the state where the patient is being treated.
Reviewing a POLST Form
This POLST form should be reviewed periodically and in light of the patient’s ongoing needs and desires. These include:
• transfers from one care setting or care level to another;
• changes in the patient’s health status or use of implantable devices (e.g., ICDs/cerebral stimulators);
• the patient’s ongoing treatment and preferences; and
• a change in the patient’s primary care professional.
Voiding or revoking a POLST Form
• A patient with capacity can void or revoke the form, and/or request alternative treatment.
• Changing, modifying, or revising a POLST form requires completion of a new POLST form.
• Draw line through sections A through E and write “VOID” across page if any POLST form is replaced or becomes invalid.
• Beneath the written "VOID" write in the date of change and re-sign.
• If included in an electronic medical record, follow all voiding procedures of facility.
Illinois Health Care Surrogate Act (755 ILCS 40/25) Priority Order
1. Patient’s guardian of person
5. Adult siblings
2. Patient’s spouse or partner of a registered civil union
6. Adult grandchildren
3. Adult children
7. A close friend of the patient
4. Parents
8. The patient’s guardian of the estate
9. The patient’s temporary custodian appointed under subsection
(2) of Section 2-10 of the Juvenile Court Act of 1987 if the court has
entered an order granting such authority pursuant to subsection
(12) of Section 2-10 of the Juvenile Court Act of 1987.
For more information, visit the IDPH Statement of Illinois law at http://dph.illinois.gov/topics-services/health-care-regulation/nursing-
homes/advance-directives
HIPAA (HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT of 1996)
PERMITS DISCLOSURE TO HEALTH CARE PROFESSIONALS AS NECESSARY FOR TREATMENT
