Set by Utah Administrative Code R432-31, this statutory order records CPR, medical intervention and artificial nutrition orders that EMS and facilities honor. Version 3.1, dated February 2019, is meant for both adult and pediatric patients. Clinicians complete it based on the patient's preferences and medical indications, and it also records how much leeway the patient gives a surrogate.
An MD, DO, PA or APRN completes Sections A to D and signs, and the patient or surrogate decision maker signs too. For pediatric patients, two different medical providers must sign, and the licensed professional who prepared the form also signs.
Download the current version from the source each time; forms change without notice.
Provider Order for Life-Sustaining Treatment (POLST) - Utah Life with Dignity Order
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Yes. The form is intended for both adult and pediatric patients. For pediatric patients, signatures from two different medical providers (MD, DO, PA or APRN) are required, in addition to the signature of the patient's surrogate decision maker, and the licensed professional who prepared the form also signs.
Yes. Use of the original form is strongly encouraged, but photocopies and faxes of signed POLST forms are legal and valid. A copy must accompany the patient whenever transferred or discharged, including transfers to hospital emergency departments.