AGING AND DISABILITY SERVICES ADMINISTRATION

2007 AFH "Dear Provider" Letters

September 24, 2007

ADSA: AFH #2007-011
PHYSICIAN ORDERS FOR LIFE SUSTAINING TREATMENT (POLST) FORM

Dear Adult Family Home Provider:

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 called the Physician Orders for Life Sustaining Treatment (POLST).

Residents of or residents admitted to adult family 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 a resident has chosen to use the POLST form you should:

• Understand that the form records a summary of the resident’s health care decisions;
• Keep the form in a place easy to get to for your staff and emergency medical personnel; and
• Send the form with the resident whenever they are transferred or discharged from your home.

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. Thank you for your continued dedication to the long-term care residents of Washington.

Sincerely,

Joyce Pashley Stockwell, Director
Residential Care Services

Enclosure