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      HIPAA PERMITS DISCLOSURE OF LaPOST TO OTHER HEALTH CARE PROVIDERS AS NECESSARY
LOUISIANA PHYSICIAN ORDERS FOR SCOPE OF TREATMENT (LaPOST)
 FIRST follow these orders, THEN contact physician. This is a Physician Order form based on the person’s medical condition and preferences. Any section not completed implies full treatment for that section. LaPOST complements an Advance Directive
and is not intended to replace that document. Everyone shall be treated with dignity and respect. Please see www.La-POST.org for information regarding “what my cultural/religious heritage tells me about end of life care.”
PATIENT’S DIAGNOSIS OF LIFE LIMITING DISEASE AND IRREVERSIBLE CONDITION:
_________________________________________________________________ _________________________________________________________________
GOALS OF CARE: _________________________________________________________________ _________________________________________________________________ _________________________________________________________________
LAST NAME _________________________________________________________________ FIRST NAME/MIDDLE NAME _________________________________________________________________ DATE OF BIRTH MEDICAL RECORD NUMBER (optional) _________________________________________________________________
 A. CARDIOPULMONARY RESUSCITATION (CPR): PERSON IS UNRESPONSIVE, PULSELESS AND IS NOT bREATHINg CHECk  CPR/Attempt Resuscitation (requires full treatment in section b)
ONE  DNR/Do Not Attempt Resuscitation (Allow Natural Death)
  When not in cardiopulmonary arrest, follow orders in B and C.
 B. MEDICAL INTERVENTIONS: PERSON HAS PULSE OR IS bREATHINg
 FULL TREATMENT (primary goal of prolonging life by all medically effective means) Use treatments in Selective Treatment and Comfort Focused treatment.
Use mechanical ventilation, advanced airway interventions and cardioversion if indicated.
CHECk  SELECTIVE TREATMENT (primary goal of treating medical conditions while avoiding burdensome treatments) Use treatments in Comfort Focused
treatment. Use medical treatment, including antibiotics and IV fluids as indicated. May use non invasive positive airway pressure (CPAP/biPAP). Do not intubate. generally avoid intensive care.
 ONE
 COMFORT FOCUSED TREATMENT (primary goal is maximizing comfort) Use medication by any route to provide pain and symptom management.
Use oxygen, suctioning and manual treatment of airway obstruction as needed to relieve symptoms. (Do not use treatments listed in full or selective treatment unless consistent with goals of care. Transfer to hospital ONLY if comfort focused treatment cannot be provided in current setting.)
ADDITIONAL ORDERS: (e.g. dialysis, etc.)
__________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________
 Medically assisted nutrition and hydration is optional when it
• cannot reasonably be expected to prolong life • would be more burdensome than beneficial • would cause significant physical discomfort
C. ARTIFICIALLY ADMINISTERED FLUIDS AND NUTRITION: (Always offer food/fluids by mouth as tolerated)
 No artificial nutrition by tube.
CHECk  Trial period of artificial nutrition by tube. (Goal: ___________________________________________________________________________________ )
ONE
 Long-term artificial nutrition by tube. (If needed)
 D. SUMMARY
The basis for these orders is:
 CHECk  ALL 
Patient’s declaration (can be oral or nonverbal) Patient’s Personal Health Care Representative (Qualified Patient without capacity)
 Advance Directive dated ________________, available and reviewed  Advance Directive not available
 No Advance Directive
 Health care agent if named in Advance Directive:
Name:__________________________________________________________ Phone: _________________________________________________________
THAT APPLY
Discussed with:  Patient (Patient has capacity)  Personal Health Care Representative (PHCR)
 Patient’s Advance Directive, if indicated, patient has completed an additional document that provides guidance for treatment measures if he/she loses medical decision-making capacity.
 Resuscitation would be medically non-beneficial.
  This form is voluntary and the signatures below indicate that the physician orders are consistent with the patient’s medical condition and treatment plan and are the known desires or in the best interest of the patient who is the subject of the document.
    PRINT PHYSICIAN’S NAME PRINT PATIENT OR PHCR NAME
PHCR RELATIONSHIP
PHYSICIAN SIgNATURE (MANDATORY) PHYSICIAN PHONE NUMbER DATE (MANDATORY) PATIENT OR PHCR SIgNATURE (MANDATORY) DATE (MANDATORY)
PHCR ADDRESS PHCR PHONE NUMbER
        SEND FORM WITH PERSON WHENEVER TRANSFERRED OR DISCHARGED
USE OF ORIGINAL FORM IS STRONGLY ENCOURAGED. PHOTOCOPIES AND FAXES OF SIGNED LaPOST FORMS ARE LEGAL AND VALID.
V2.06.13.2016
 


















































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