Provider Order for Life-Sustaining Treatment

The Provider Order for Life-Sustaining Treatment (POLST) form is a concise medical order completed by a person's physician, APRN or physician's assistant after a discussion to determine which treatments the patient wants and does not want near the end of life.

The POLST is introduced by a patient's health care provider when they are caring for frail or elderly patients or patients near the end of a serious, progressive disease. The form includes resuscitation orders and three levels of end-of-life interventions. The POLST cannot be honored unless it is signed by the patient their legal representative or surrogate and the patient's physician, APRN or physician's assistant.

  • Video Introduction to POLST
    • Note: Video is pending updates to the POLST form (11/7/17)

Ordering POLST forms

Nevada POLST forms may be ordered by clicking here. Because the POLST is a medical order, only health care facilities or health care providers are able to order POLST forms. Information on how to complete the form, talking to patients or their loved ones about the POLST, patient handouts and other important information is available from the non-profit Nevada POLST.

POLST forms may be printed; however, it is preferred that this form be printed double-sided on hot pink paper to make it more easily identifiable. This is a recommendation to better ensure easy recognition, it is not a requirement

    Filing of POLST

    It is recommended that the completed form be registered with the Living Will Lockbox through the Nevada Secretary of State Office for easy retrieval. Information regarding the Living Will Lockbox can be found at the Nevada Secretary of State's Living Will Lockbox website. All medical providers of the patient should have a copy for their records to ensure that they know the patient's wishes.

    The Nevada POLST law went into effect June 2013, with revision in June 2017. Nevada POLST, a nonprofit created to educate health care providers and the public regarding the POLST program, and the Division of Public and Behavioral Health collaborated to create the current POLST form. Nevada POLST has additional information, including patient education handouts and videos, POLST completion instructions and research, on their website at www.nevadapolst.org.

    Out-of-Hospital Do Not Resuscitate

    An Out-of-Hospital Do Not Resuscitate (DNR) order governs whether a person will be resuscitated if his/her heart stops (cardiopulmonary arrest). Resuscitation is the only treatment a DNR covers.

    Submit a DNR

    Download and save the file to your computer, complete the form, and mail to the Division of Public and Behavioral Health at the address indicated on the form. Please note if utilizing a DNR for Clark County please visit www.southernnevadahealthdistrict.org

      Advance Directives

      As the name implies, Advance Directives are documents created before someone experiences a health crisis. Advance Directives are also called Living Wills. They are a person’s best guess at what they will want if a life-threatening event occurs. Although not required, it is best to complete an Advance Directive after consultation with your health care provider so you can clearly understand what the medical treatment choices will mean for you.

      There are generally two parts to an Advance Directive: a Durable Power of Attorney for Health Care (DPOA-HC) and a Declaration. The DPOA-HC is a legal document used to identify who will speak for you in the event you are unable to communicate your wishes yourself. This is a very important decision because this person will be able to decide what treatments you may or may not receive including life-sustaining measures such as resuscitation, artificial hydration and nutrition or a breathing tube. The person you designate as your DPOA-HC should know your wishes and values and be willing to carry out those wishes. Be sure this person knows they are your DPOA-HC and give them a copy of your DPOA-HC document.

      The second part of an Advance Directive is the Declaration. This document explains what you want if you are in a coma or have a terminal illness and cannot express your wishes yourself.

      To complete an Advance Directive online, visit NVLivingWill.com or ask your health care provider for the documents. Both the DPOA-HC and Declaration are legal documents and require either two witnesses or a notary public to sign them. Once completed, copies should be given to your physicians, your DPOA-HC and anyone else who may be contacted if you experience a health crisis. Finally, the documents should be submitted to the Living Will Lockbox.

      Many people do not realize that, because an Advance Directive is not a medical order, if their heart should stop emergency medical responders (ambulance personnel) are required to attempt resuscitation even if your Advance Directive states that you do not want to be resuscitated. Only a POLST or Out-of-Hospital DNR is effective in avoiding resuscitation efforts.

        Differences Between a POLST, Out-of-Hospital DNR and Advance Directive

        A POLST is for the very frail elderly or anyone, including children, who is near the end of a life-limiting illness. The Out-of-Hospital DNR is for those with a terminal diagnosis. An Advance Directive is for anyone over 18 years of age in any state of health — good or bad.

        A POLST governs both resuscitation and other treatments that a patient may or may not want near the end of life. An Out-of-Hospital DNR only governs resuscitation outside of a hospital. An Advance Directive provides guidance regarding a patient’s wishes for resuscitation, artificial hydration and nutrition and a balance of benefit and burden.

        The POLST and Out-of-Hospital DNR are medical orders to be honored by health care providers. An Advance Directive is a legal document, not a medical order. It, therefore, is not effective to avoid resuscitation outside of a hospital; either a POLST or Out-of-Hospital DNR is required.

        There is no charge for a POLST or Advance Directive. There is a $5 charge for an Out-of-Hospital DNR.

        A POLST is active as soon as it is signed by a physician and the patient or their legal representative. The Out-of-Hospital DNR is active after it is signed by the patient and their physician, sent to the responsible state agency (see above) along with a payment of $5 and returned to the patient by mail. An Advance Directive is effective as soon as it is signed by the patient and two witnesses or a notary public.

           

           

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