1. Does your hospital have a formal policy on how to complete and follow POLST forms?
____ Yes → Whom might we contact to obtain a copy of the policy?
____ No
2. Are blank (pink or other) POLST forms available in your hospital to complete with patients?
____ Yes
____ No
3. Usually in hospitals, a particular department or area “owns” specific interventions or aspects of care. In your hospital, who “owns” the POLST?
___ No one department or area
___ Don’t know
4. Have hospital staff received education about POLST?
____ Yes ____ No → Skip to question 6
5. Describe the hospital education about POLST, types of materials used and who conducted the education:
6. Has your hospital ever admitted a patient who already had a completed POLST?
____ Yes ____ No ____ Don’t know
7. If a patient presents to the Emergency Department with a POLST containing a DNR order and suffers a cardiopulmonary arrest in the ED, how would the ED physicians respond? (Choose one answer)
____ Respect the POLST as a physician order and withhold CPR
____ Consider the POLST as information about patient preferences to be combined with other
information in deciding whether to initiate CPR.
____ Physicians will choose whether to initiate CPR according to their individual practice.
____ I don’t know.
____ This hospital has no Emergency Department.
8. If a patient is admitted to your hospital with a completed POLST that contains physician orders concerning resuscitation, how would the attending physician regard the POLST? (Choose one answer)
____ Copy the POLST resuscitation order into the hospital admission orders.
____ Consider the information in the POLST as information about patient preferences to be
combined with other information in deciding what orders to write.
____ Physicians will handle the POLST according to their individual practice.
____ I don’t know.
9. If a patient admitted to your hospital enters the hospital with a completed POLST, what would the healthcare team do with the POLST document? (Choose one answer)
____ Place the original POLST into the medical record
____ Place a copy/Scan the POLST into the medical record and return the original to the patient
____ Not incorporate the POLST into the medical record because it is not a hospital document.
____ Physicians will handle the POLST differently on various hospital units.
____ Physicians will handle the POLST according to their individual practice.
____ I don’t know.
10. A patient is admitted to the hospital from home and during the hospitalization decided with her physicians that care should be comfort-oriented and should not include resuscitation. A DNR order is placed in the hospital chart. The patient will be discharged to a SNF.
What is the likelihood, from 0 to 100%, that on discharge to the SNF, the patient would have a POLST form created capturing her decisions? ______%
11. Has your hospital encountered any problems with POLST forms?
____ No ____ Yes → Please describe below
12. Would your hospital benefit from any assistance in the use of the POLST?
____ No ____ Yes → Please describe below
____ Educational program for staff
____ Example policy for completing and/or following POLST documents
____ Other:
THANK YOU