Health, Department of

Provider Orders for Life Sustaining Treatment (POLST)

Chapter 1: Provider Orders for Life Sustaining Treatment Act

Effective Date: 04/12/2016 to Current

Rule Type: Current Rules & Regulations

Reference Number: 048.0068.1.04122016

WYOMING DEPARTMENT OF HEALTH

AGING DIVISION

CHAPTER 1

RULES FOR PROVIDER ORDERS FOR LIFE SUSTAINING TREATMENT (POLST)

Section 1. Authority. These rules are promulgated by the Wyoming Department of Health pursuant to W.S.§ 35-22-501 through 509.

Section 2. Definitions.

(a) “Cardiopulmonary resuscitation bracelet” means the unique, immediately recognizable bracelet of uniform size and design issued by the Department to the declarant, to be worn for immediate identification of the declarant by emergency medical service (EMS) personnel and health care providers. The bracelet shall be considered the same as and have the same effect as an apparent, immediately available and identified cardiopulmonary resuscitation (CPR) directive.

(b) “Cardiopulmonary resuscitation directive form” means the document provided by the Department that is printed on distinctive security paper and is filled out by the declarant and attending physician to execute a CPR directive.

(c) “POLST” means Provider Orders for Life-Sustaining Treatment, the statewide method of identifying a patient’s wishes regarding medical treatment when faced with life limiting illnesses, and converting those wishes into a set of medical orders.

(d) “POLST Form” is the standardized and easily identifiable document, approved by the Department, which converts a patient’s goals of care and treatment preferences into a provider order that transfers across health care settings.

“Primary Health Care Provider” per W.S. § 35-22-402.

Section 3. Provider Orders for Life Sustaining Treatment (POLST) Forms.

(a) An individual who wishes to execute a POLST Form must use the form approved by the Department. The form may not be altered in layout or style, including font style and size.

(b) Any person, health care provider or health care facility may obtain a POLST Form from the Department and from the Department’s website.

(c) A health care provider, licensed health care facility or EMS provider shall act upon a copy of a POLST Form as if it were original.

(d) The standardized POLST Form shall contain: (i) The person's name, date of birth, and gender; (ii) Standard protocols, recognized nationally, regarding end-of-life care; (iii) Medical condition and patient goals; (iv) An area allowing the person, executing the form, to forbid any changes to be made by the surrogate; (v) Printed name, address, and telephone number of the Primary Health Care Provider; (vi) Signature of Primary Health Care Provider; (vii) Signature of person executing the POLST Form; and (viii) Dates of signatures;

Section 4. Method of Identification.

(a) The POLST Form shall be printed on gold paper in order to be easily identifiable for patients and caregivers. (b) Individuals, who have executed a POLST Form, shall be instructed to post a copy of the form in a visible area in their place of residence.

Section 5. Prior Orders and Out of State Orders.

(a) A POLST Form from another state, absent actual notice of revocation or termination, shall be presumed to be valid in this state. (b) A POLST Form executed prior to this rule, from this state and other states, absent actual notice of revocation or termination, shall be presumed to be valid in this state. (c) All previously issued CPR bracelets and CPR directive forms, from this state and other states, shall be considered valid.

Section 6. Responsibilities.

(a) A Primary Health Care Provider who is completing a POLST Form with a patient shall ensure that the patient:

(i) Receives an explanation of the expected consequences of choices made for each section of the POLST Form;

(ii) Is informed that if the POLST Form is not apparent and immediately available, interventions may be initiated by EMS personnel; and

(iii) Receives an explanation of how and by whom the POLST Form may be revoked or changed.

(b) The person executing a POLST Form is:

(i) Responsible for making informed decisions concerning the choices made within each section of the POLST Form;

(ii) Encouraged to post the completed POLST Form in a visible location in their place of residence; and

(iii) Responsible for notifying family members, next of kin, and the surrogate named within the POLST Form, of the existence of a completed POLST Form.