Patient Name: GOEHLER, WILLIAM ROBERT
Date of Birth: 2/15/1963 00:00 PST
Between The Bars
* Auth (Verified) *
STATE OF CALIFORNIA
DEPARTMENT OF CORRECTIONS AND REHABILITATION
PHYSICIAN ORDERS FOR LIFE-SUSTAINING TREATMENT (POLST)
CDCR 7465 (Rev. 08/16)
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HIPAA PERMITS DISCLOSURE OF POLST TO OTHER HEALTHCARE PROVIDERS AS NECESSARY
Physician Orders for Life-Sustaining Treatment (POLST)
First follow these orders, then contact Physician/NP/PA.
A copy of the signed POLST form is legally valid physician order. Any section not completed implies full treatment for that section. POLST complements an Advance Directive and is not intended to replace that document.
Patient Last Name: Goehler
Patient First Name: William
Patient Middle Name:
Date Form Prepared: 12/5/17
Patient Date of Birth: 2/15/1963
Medical Record #: (optional) K77832
EMSA #111 B
CARDIOPULMONARY RESUSCITATION (CPR):
If patient has no pulse and is not breathing.
If patient is NOT in cardiopulmonary arrest, follow orders in Section B and C.
[ ] Attempt Resuscitation/CPR (Selecting CPR in Section A requires selecting Full Treatment in Section B)
[X] Do Not Attempt Resuscitation/DNR (Allow Natural Death)
If patient is found with a pulse and/or is breathing.
[ ] Full Treatment - primary goal of prolonging life by all medically effective means.
In addition to treatment described in Selective Treatment and Comfort-Focused Treatment, use intubation, advanced airway interventions, mechanical ventilation, and cardioversion as indicated.
[ ] Trial Period of Full Treatment
[ ] Selective Treatment - goal of treating medical condition while avoiding burdensome measures.
In addition to treatment described in Comfort-Focused Treatment, use medical treatment, IV antibiotics, and IV fluids as indicated. Do not intubate. May use non-invasive positive airway pressure. Generally avoid intensive care.
[ ] Request transfer to hospital only if comfort needs cannot be met in current location.
[X] Comfort-Focused Treatment - primary goal of maximizing comfort.
Relieve pain and suffering with 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. Request transfer to hospital only if comfort needs cannot be met in current location.
ARTIFICIALLY ADMINISTERED NUTRITION:
Offer food by mouth if feasible and desired.
[ ] Long-term artificial nutrition, including feeding tubes.
[ ] Trial period of artificial nutrition, including feeding tubes.
[X] No artificial means of nutrition, including feeding tubes.
INFORMATION AND SIGNATURES:
[X] Patient (Patient Has Capacity)
[ ] Legally Recognized Decisionmaker
[ ] Advance Directive dated ___ available and reviewed --> Healthcare Agent if name in Advance Directive:
[ ] Advance Directive not available
[ ] No Advance Directive
Signature of Physician / Nurse Practitioner / Physician Assistant (Physician/NP/PA)
My signature below indicates to the best of my knowledge that these orders are consistent with the patient's medical condition and preferences.
Print Physician/NP/PA Name:
Physician/NP/PA Phone #:
Physician/NP/PA License #:
Physician/NP/PA Signature: (required)
Signature of Patient or Legally Recognized Decisionmaker
I am aware that this form is voluntary. By signing this form, the legally recognized decisionmaker acknowledges that this request regarding resuscitative measures is consistent with the known desires of, and with the best interest of, the patient who is the subject of the form.
Relationship: (write self if patient)
Mailing Address (street/city/state/zip):
Office Use Only:
SEND FORM WITH PATIENT WHENEVER TRANSFERRED OR DISCHARGED
*Form versions with effective dates of 1/1/2009, 4/1/2011 or 10/1/2014 are also valid.
RECEIVED DEC 05 2017
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