AGING AND DISABILITY SERVICES ADMINISTRATION

2007 BH "Dear Provider" Letters

September 24, 2007

ADSA: BH #2007-015
PHYSICIAN ORDERS FOR LIFE SUSTAINING TREATMENT (POLST) FORM

Dear Boarding Home Administrator:

The Department of Health (DOH) and Emergency Medical Service (EMS) personnel developed a form for a resident and the resident’s physician to use to document the resident’s end-of-life decisions about health care. The form is the Physician Orders for Life Sustaining Treatment (POLST).

Residents of boarding homes may decide to use the POLST to document decisions such as but not limited to:

• Code/No Code or Do Not Resuscitate (DNR);
• Tube feedings; and / or
• Use of antibiotics.

If the resident chooses to use the POLST form it is recommended that the POLST form be placed in front of the resident record. The resident and the resident’s physician must sign and date the POLST form before EMS personnel can use the form.

If the resident has a POLST form, the original form should be sent with them when they are transferred or discharged to another setting. The form can then be used by the admitting home to provide beginning information about the resident’s end of life wishes until the home can get other current information.

You may get more information to assist you and your residents understand the resident’s legal rights to make decisions about health care, advanced directives, informed consent, at the following Internet links:

• Fact Sheets:
  • Advance Directives and Informed Consent
  • Physician Orders for Life Sustaining Treatment (POLST)
• Your Legal Right to Make Decisions About Health Care and Advance Directives in Washington State

A copy of the POLST form is enclosed. We encourage you to read and share this information with each of your residents.

Sincerely,

Joyce Pashley Stockwell, Director
Residential Care Services

Enclosure