Provider Order for Life-Sustaining Treatment (POLST) Utah ... 2026

1. Click ‘Get Form’ to open the Provider Order for Life-Sustaining Treatment (POLST) Utah in the editor.
2. Begin by entering the patient's last name, first name, middle initial, date of birth, and last four digits of their Social Security number. This information is crucial for identifying the patient.
3. Fill in the effective date of this order and the patient's address, including street, city, state, and zip code.
4. Next, provide details about the medical provider's name and phone number. This section ensures that healthcare professionals can be contacted easily.
5. In Section A, select one option regarding cardiopulmonary resuscitation (CPR). Choose between 'Attempt to resuscitate' or 'Do not attempt resuscitation.'
6. Proceed to Section B to choose medical interventions based on whether the patient has a pulse and is breathing. Options include 'Full Treatment,' 'Limited Additional Interventions,' or 'Comfort Measures.'
7. Complete Section C regarding artificial nutrition preferences. Indicate if a trial period is desired or if no artificial nutrition is preferred.
8. Finally, ensure all required signatures are obtained from both the medical provider and patient or surrogate decision-maker to validate the form.

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