Illinois’s IDPH DNR/POLST Form

Illinois’s IDPH DNR/POLST Form
Educational presentation developed by Kelly Armstrong, PhD Approved by the Education Committee of the POLST Taskforce Notes comments by Julie Goldstein, MD Illinois’s IDPH DNR/POLST Form New Documentation for Patients & Quality Care Revised 1/18/15

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This slide presentation may be used without permission. To promote consistency across the state, the slides may not be altered. You may freely take language (but not screenshots) from this presentation to use in your own presentations. Please send requests for institutionally specific modifications to or

The POLST Document Objectives
By the end of this session, participants will be able to: Understand the POLST Paradigm and how patient wishes are determined and documented in a standard form Describe the relationship between a Power of Attorney for Healthcare and a POLST form, and when each is appropriate for patient completion Recognize the importance of healthcare staff being properly educated regarding interpreting POLST forms during emergencies and other relevant circumstances

IDPH DNR/POLST form … and national POLST standards
Illinois recently modified the current IDPH DNR/POLST form to come closer to the national POLST standards used in other states POLST stands for “Practitioner Orders for Life-Sustaining Treatment”** POLST reduces medical errors by improving guidance during life-threatening emergencies ** The 2014 version of the form was called “Physician Orders for Life-Sustaining Treatment” 4

POLST Use in the United States
The POLST Paradigm is now in the majority of states Oregon released the first POLST form in 1995 Gradually expanded throughout the U.S. 15 states with endorsed programs 28 states developing programs (including IL) The national POLST Paradigm Initiative Task Force aids state programs with patient safety, quality improvement, and educational resources 5

Evolution of the IDPH DNR Form
2015 2000 2007 2006 2005 2013 Evolution of the IDPH DNR Form “Orange” DNR Form IDPH Uniform DNR “Order Form” IDPH Uniform DNR “Advance Directive” 2013 – POLST Added The IDPH approved form developed by a statewide consortium of providers, ethicists, and other stakeholders becomes widely available. POLST Language Added Who Can Sign Medical Order is Expanded Illinois is unique in that our POLST form has evolved from previous versions of out-of-hospital DNR order forms. This is the fourth version and offers patients and providers both more options and more concrete guidance. 6

Benefits of IDPH DNR/POLST in Illinois
Promoting Patient-Centered Care Promotes quality care through informed end-of-life conversations and shared decision-making Concrete Medical Orders that must be followed by healthcare providers Easily recognized standardized form for the entire state of Illinois Follows patient from care setting to care setting 7

Key Factors Work Together to Help POLST Work
Color Location Transportability The pink color helps the form stand out for easier identification. Any color paper is valid; pink is preferred Organizations should assist persons in choosing a standard location in their local area where POLST is kept Designed to stay with the patient as the patient is transported to a new facility & must be honored in all locations 8

Why Does Illinois Need This Document?

To Insure Accuracy and Continuity of Patient Wishes Across Care Settings
Ave. of 34 Physician Visits in last 6 months of life Ave. of 11 Different Physicians in last 6 months of life Now imagine that every visit involves multiple care providers and medical records (nursing staff, procedurists, technicians, radiology staff, etc). All of those persons must be prepared to respond appropriately in an emergency. If the patient goes for an Xray – would the staff know how intensely to intervene if the patient developed acute severe respiratory distress? Just because one physician had an appropriate discussion with the patient and elicited the patient’s wishes, does not mean that information is readily available from the clinic, to the nursing home, to the ambulance, to the ED staff, to the ICU. We need a single easy mechanism to ensure that all providers have the necessary information. 10

Who is IDPH DNR/POLST Designed For?
Focusing on patients as partners in their care. The POLST paradigm is designed for: Patients facing life-threatening complications, regardless of age; and/or Patients with advanced serious illness or frailty POLST is not for use by the general public. It is specifically meant to be used by patients who meet these criteria. 11

Screening Question A POLST discussion is appropriate if:
One Year is a Rule of Thumb… A POLST discussion is appropriate if: You would not be surprised if this person died from their illness(es) within the next year The patient suffers from a severe illness and has a preference about the intensity of his/her care 12

Advance Care Planning Over Time
Maintain and Maximize Health, Choices, and Independence First Phase: Complete a PoA. Think about wishes if faced with severe trauma and/or neurological injury. Next Phase: Consider if, or how, goals of care would change if interventions resulted in bad outcomes or severe complications. Last Phase: End-of-Life planning - establish a specific plan of care using POLST to guide emergency medical orders based on goals. Healthy and Independent Advancing Chronic Illnesses and Functional Decline Multiple Co-Morbidities and Increasing Frailty The segmented bar in the middle represents the 3 “phases” of the Advance Care Planning “Life Cycle.” There is much information here, and most likely it will need to be briefly summarized in order to get through the entire presentation. The First Phase begins at adulthood. Once someone becomes an adult, they should be encouraged to start advance care planning as a healthy life habit. For a Healthy and independent adult, there are only a few advance care planning “tasks”. The first is to consider “Who in my life would I trust to represent my medical wishes if I couldn’t speak for myself?”. The second is to put that choice in writing in the form of a power of attorney for healthcare document. The third is to consider “If I suddenly became irreversibly neurologically devastated, ie., vegetative, would I want ongoing treatment or would I want to be allowed to die?” (be aware that this is a controversial subject for observant Catholics). The fourth is to notify the selected agent, and give that person a copy of the document. These are the “First Steps”. The Next Phase begins when a patient has a chronic illness that has begun to advance such that there is a functional decline. For this patient, the life habit continues, and is built upon the considerations in the First Phase. Now it is time to think about one’s specific conditions and the specific kinds of deterioration that can be can be expected with those conditions. For example, a person who has COPD is now requiring oxygen use at home, and/or is experiencing hospital admissions for acute exacerbations. That patient should understand the risk of being intubated and the nature of that procedure including its benefits and burdens. The patient should also consider whether, if unweanable, tracheostomy and longer-term care in a facility that treats patients on ventilators would be acceptable, and if so, would there come a point when it would no longer be acceptable? If there are no limitations of treatment desired at this point, there is not a new document to complete here, but specific discussion about specific treatment wishes is appropriate, with both the primary care provider as well as the identified agent. These are the “Next Steps”. The Last Phase is when a patient is likely to be in the last year or so of life, as mentioned. This is the patient with multiple comorbities and/or increasing frailty. In this phase, it is possible that the person making decisions is not even the patient, but instead the substitute decision-maker (who is ideally also the assigned agent with Power of Attorney for Health Care). In this phase, there are specific decisions to be made, including wishes about CPR in case of cardiac arrest, and in other critical conditions, level-of-treatment wishes based on patient goals, which can range from strictly comfort care all the way to aggressive treatment with all medically indicated means. These are the “Last Steps”, and are documented on the POLST form so that ALL providers who may encounter this patient in an emergency situation will have guidance regarding the desired treatment(s). Document on Power of Attorney form Document on IDPH DNR form 13

The IDPH DNR/POLST Form in Illinois

The IDPH DNR/POLST Document
The POLST Document The IDPH DNR/POLST Document 3 Primary Medical Order Sections CPR for Full Arrest Yes, Attempt CPR No, Do Not Attempt CPR (DNR) Orders for Pre-Arrest Emergency Full Treatment Selective Treatment Comfort Focused Medically Administered Nutrition Acceptable Trial Period None NEW This slide shows the general outline of decision categories in the POLST form, as compared to the “old” IDPH DNR Advance Directive to which we are accustomed. We will go in detail through each of the sections. One of the most important things to notice immediately, is that, unlike the old form, the mere existence of a POLST form does not imply that the patient is DNR in case of a cardiac arrest. This is a critical change to this Section of the form, and an important safety issue. Section B still addresses pre-arrest emergencies, but the levels of treatment instructions are much more detailed and understandable compared to the old form. And Section C is brand-new. NEW 15

Practitioner Orders for Life-Sustaining Treatment R E D C B A Cardio-Pulmonary Resuscitation (CPR) Medical Interventions Artificially Administered Nutrition Medically Administered Nutrition Documentation of Discussion Signature of Attending Practitioner Reverse Side – Contains More Information and Instructions 16

Section “A”: Cardio-Pulmonary Resuscitation
Code Status – only when pulse AND breathing have stopped Again, notice that unlike the previous versions of the form, the POLST form may also be used when a patient wants to document that s/he in fact WOULD accept CPR in case of cardiac arrest. Of course, “Yes to CPR in case of cardiac arrest” is our default instruction in any case. And with the old form, there was no reason to even have it if the patient wanted CPR in case of cardiac arrest. But because the POLST form now allows for a yes or no answer, the form has become somewhat more complex. The good news is, the same content that adds complexity also supports patients in documenting their wishes more specifically and allows them to know that their wishes will be followed. There are multiple kinds of emergencies. This section only addresses a full arrest event (no pulse and not breathing), and answers “Do we do CPR or not?” NOTE! Patients can use this form to say YES to CPR, as well as to refuse CPR. 17

Practitioner Orders for Life-Sustaining Treatment R E D C B A Cardio-Pulmonary Resuscitation (CPR) Medical Interventions Artificially Administered Nutrition Medically Administered Nutrition Documentation of Discussion Signature of Attending Practitioner Reverse Side – Contains More Information and Instructions 18

Section “B”: Medical Interventions
Do Not Resuscitate does NOT mean Do Nothing Section B now is now formatted according to intensity of treatment wishes in pre-arrest situations. Which level is selected will be based on the patient’s specific medical conditions, plus what is medically feasible, plus the patient’s own goals of care. There are three levels of treatment, which can be thought of as “Strictly Comfort Care”, “Limited but Noninvasive Medical Interventions”, and “Full Treatment with all Medically Indicated Treatments” (a.k.a. the “Intubation and Mechanical Ventilation” intensity level). Three categories explaining the intensity of treatment when the patient has requested DNR for full arrest, but is still breathing or has a pulse. Full – all indicated treatments are acceptable Selective – no aggressive treatments such as mechanical ventilation Comfort – patient prefers symptom management and no transfer if possible 19

Use “Additional Orders” for other treatments that might come into question (such as dialysis, surgery, chemotherapy, blood products, etc.). An indication that a patient is willing to accept full treatment should not be interpreted as forcing health care providers to offer or provide treatment that will not provide a reasonable clinical benefit to the patient (would be “futile”). Note here that a treatment is said to be “futile” if it does not meet the goals for patient. (The challenge here is that it is not always clear whose goals are being considered: is it the patient’s goals or the providers’ goals being considered?). A full discussion of the meaning of “futility” is beyond the scope of this presentation, but the key concept is that although a patient may be willing to receive a treatment, that willingness does not force a provider to go against medical standards of care to provide it. 20

Order Reversed 2014 form versus 2015 form
The language was changed to better reflect actual conversations which generally begin with doing everything, before moving to any restrictions the patient/family may wish to place on treatments. 21

Yes to CPR in Section A requires full treatment in Section B If choosing “Attempt CPR” in Section A, Full Treatment is required in Section B. Why? If limited measures fail and the patient progresses to full arrest, the patient will be intubated anyway, thus defeating the purpose of marking Comfort or Selective. 22

Section “A” choices influence medical interventions in Section “B”
Yes! Do CPR Full Treatment Full Treatment or DNR: No CPR Note that DNR for full arrest does NOT require documentation of a qualifying condition when requested by a Surrogate. This is because once the patient goes into full arrest, they now have a qualifying condition. It would not make sense to wait until that moment to make appropriate plans. Selective Interventions * or * Comfort Measures *Requires documentation of a “qualifying condition” ONLY when requested by a Surrogate. 23

For Example… 85 year-old gentleman admitted from home through ED with severe pneumonia The patient is increasingly hypoxic and may be confused Patient refuses the vent x3. There is a DNR order on the chart. The physician feels DNR does not apply to potentially reversible conditions and begins full resuscitation. 24

POLST Clarifies Unclear Guidance
85 year-old gentleman admitted from home through ED with severe pneumonia The patient is increasingly hypoxic and may be confused Patient refuses the vent x3. There is a DNR order on the chart. Comfort only is marked for medical treatment. Intensive symptom management is started and resuscitation is not initiated. 25

For example… A 59 year-old woman being treated for breast cancer arrives at the ED with sepsis. In the ICU, she is on oxygen and maxed-out on pressors. She has a DNR order on the chart. Staff are concerned they are violating the patient’s wishes. 24

POLST Addresses Ethical Concerns
A 59 year-old woman being treated for breast cancer arrives at the ED with sepsis. In the ICU, she is on oxygen and maxed-out on pressors. She has a DNR order on the chart. Selective treatment is marked for medical treatment. Staff can feel comfortable they are honoring the patient’s wishes. 25

For example… 67 year-old gentleman presents to ED with chest pain and SOB. He is in pain and confused. The cardiologist wants to take him for a cardiac cath and possible stent. The patient’s nurse calls the physician to inform her that the patient has a prior IDPH DNR order on the chart. There is confusion whether the patient would want to be sent for the procedure anyway. 26

POLST Provides Guidance for Treatment
67 year-old gentleman presents to ED with chest pain and SOB. He is in pain and confused. The cardiologist wants to take him for a cardiac cath and possible stent. The patient’s nurse calls the physician to inform her that the patient has a prior IDPH DNR order on the chart. Full treatment is marked for medical treatment and he is immediately sent for the recommended treatment. This slide highlights the difficulty providers have when responding to an emergency when the complete medical history is not immediately available the only information they have is a DNR form that doesn’t apply until the patient goes into full arrest. The staff would have to go back and comb through the past medical records to find the conversation with the patient and the patient’s goals given his medical condition. The POLST form allows providers to act quickly when minutes count which gives them the time they need to get to this important information in the past medical history. 27

Don’t Forget DNR for Procedures…
Best Practice: DNR Is Not Automatically Lifted Consent needs to be obtained to change an existing DNR order to full code, even during a procedure Discuss appropriateness of DNR in light of procedure and objectives If suspended, specify length of time Inform procedurists of code status Physicians may still say to the patient that they need the ability to reverse iatrogenic complications caused by the surgery itself or anesthesia, and thus need to suspend the DNR for the period of the surgery and possibly for an agreed upon time afterward. The key point here is that the patient is both informed and agrees to the suspension. 30

Creating More Accurate Orders
Some institutions have created orders to better capture the distinction of these categories, such as DNR-Comfort, DNR-DNI, or DNR-Full Treatment. Hospitals are NOT required to complete this form when writing in-hospital DNR orders for the first time. Complete a IDPH DNR/POLST form if the patient/legal representative wishes to continue DNR code status or limit emergency medical interventions after discharge. DNR refers to the orders in Section A, whereas Comfort or DNI or Full refers to the orders in Section B. 31

Of 25,000 people in Oregon… Yes to CPR (28%) No CPR: DNR (72%) ½ of the DNR group wanted hospitalization and some level of treatment for medical emergencies ½ of the DNR group wanted only comfort measures for medical emergencies 1 out of 4 patients wants CPR. This is a big change from previous forms where having the form meant DNR of some sort. Now people can use the form to make sure that they get CPR. Huge safety risk to assume presence of form means DNR only. ½ of patients who ask for DNR still want some form of treatment. Slide 30: There are two important messages to this slide. The first is that, while we assume that patients would be most likely to complete a POLST form in order to limit life-sustaining treatment, in fact, a quarter of patients actually want CPR in case of cardiac arrest. The second is that “DNR does not mean Do Nothing”, as evidenced here by the fact that even for those who opted to be DNR in case of cardiac arrest, a full half of them wanted some level of treatment beyond just comfort care in case of a pre-arrest emergency. Oregon has one of the oldest POLST programs in the United States. In Oregon, POLST forms are entered into a registry, allowing emergency personnel and hospitals 24-hour access to POLST information when the physical form cannot be located during an emergency. Clinicians in Oregon are required by law to submit forms to the registry unless the patient opts out. In examining this registry, one out of four patients wanted CPR and full treatment, while 3 out of 4 patients wanted DNR for full arrest, with half of that DNR group wanted some form of medical treatment for medical emergencies, with the other half of the DNR group wanting comfort only during medical emergencies. (43% of the DNR group wanted limited interventions, while only 6% of patients with a DNR for full arrest also wanted full treatment.) JAMA. 2012;307(1):34-35 Full treatment Limited treatment Comfort Only 32

Practitioner Orders for Life-Sustaining Treatment R E D C B A Cardio-Pulmonary Resuscitation (CPR) Medical Interventions Medically Administered Nutrition Documentation of Discussion Signature of Attending Practitioner Reverse Side – Contains More Information and Instructions 33

Section “C”: Medically Administered Nutrition
Medically Administered Nutrition can include temporary NG tubes, TPN, or permanent placement feeding tubes such as PEG or J-tubes. A trial period may be appropriate before permanent placement, especially when the benefits of tube feeding are unknown, or when the patient is undergoing other types of treatment where nutritional support may be helpful. 34

Of 25,000 people in Oregon… CPR group DNR group 2% 18% 22% 24% 60% 74%
The majority of the CPR group wanted a time-limited trial of tube feeding to see if the feeding could restore an acceptable level of functioning. The majority of people in the DNR group did not want tube feeding. Persons wishing to accept long-term tube feeding was low for both groups. CPR group 22% Long-term 60% Trial 18% None DNR group 2% Long-term 24% Trial 74% None Slide 35: Again, this slide reinforces the concept that “DNR does not mean Do Nothing”. It also demonstrates that there is a broad diversity of choices regarding artificial nutrition. Long-Term feeding tube Time-limited Trial No feeding tube JAMA. 2012;307(1):34-35 35

Practitioner Orders for Life-Sustaining Treatment R E D C B A Cardio-Pulmonary Resuscitation (CPR) Medical Interventions Medically Administered Nutrition Documentation of Discussion Signature of Attending Practitioner Reverse Side – Contains More Information and Instructions

Section “D”: Documentation of Discussion
The form can be signed by: The patient The agent with a PoA (when the patient does not have decisional capacity) The designated Healthcare Surrogate when the patient does not have decisional capacity and has no PoA or applicable Advance Directive a parent of a minor child is a surrogate a guardian is also a surrogate The legal representative may only sign this document if the physician has determined that the patient is unable to give his/her own informed consent on these matters. 37

Quick Refresher on Decision-Maker Priority
Start at the top and move down the list Patient Do not move on until patient has been evaluated by the attending physician who documents the patient lacks decisional capacity and is not expected to regain capacity in time to make this decision Power of Attorney for Healthcare Patient has completed and signed this Advance Directive Surrogate (when you can’t speak to patient and no PoA) Court-Appointed Guardian Spouse/ Civil partner Adult children Parents Adult siblings Grandparents/Grandchildren Close Friend

Decisional Capacity It’s not all or nothing. Before turning to a PoA or Surrogate, assess and document Decisional Capacity. The patient may be able to make some decisions even if s/he can’t make all decisions. Patients who are minors should be offered the opportunity to participate in decision-making up to their level of understanding Studies consistently show that decisions made by others are more aggressive and not as accurate as what the patient would choose for him/herself. Remember that the patient has the right to accept or decline medical treatment as long as s/he has the capacity to do so. Patients may have decisional capacity for one task but not another, depending on the complexity and gravity of the decision-making task in question. For a substitute decision-maker to be authorized to act on behalf of a nondecisional patient, the physician must determine based on medical judgment that the patient lacks decision making capacity. Details of such a determination are beyond the scope of this talk. Of course, it is ideal to have a discussion about care preferences near the end-of-life with the patient him- or herself whenever possible, especially given that the literature consistently shows that substitute decision-makers do not make the same decisions that patients would have, and their choices tend toward more aggressive care than the patients would have wanted. 39

According to IDPH, “one individual, 18 years of age or older, must witness the signature of the patient or his/her legal representative’s consent... A witness may include a family member, friend or health care worker.” The witness CAN NOT be the same practitioner as the one who signs the order. Direct care providers are persons who have control over the patient’s medical choices and treatment plan. Common sense and practicality must be used here: the purpose of a witness signature is to provide a “third party” protection of the patient, to assure that the patient is in fact engaging in a fully informed decision-making process and is not being coerced by the physician. If a resident physician or another nurse signs as a witness, does this comfortably demonstrate to all that the patient is not being coerced by the attending physician? There is a risk that the answer could be no. On the other hand, there are circumstances, for example, in home hospice, where there are very few persons available to sign as a witness. Follow your own institutional guidance/policies. 40

When the form is completed by a person other than the patient, it should be reviewed with the patient if the patient regains decisional capacity to ensure that the patient agrees to the provisions. Direct care providers are persons who have control over the patient’s medical choices and treatment plan. Common sense and practicality must be used here: the purpose of a witness signature is to provide a “third party” protection of the patient, to assure that the patient is in fact engaging in a fully informed decision-making process and is not being coerced by the physician. If a resident physician or another nurse signs as a witness, does this comfortably demonstrate to all that the patient is not being coerced by the attending physician? There is a risk that the answer could be no. On the other hand, there are circumstances, for example, in home hospice, where there are very few persons available to sign as a witness. Follow your own institutional guidance/policies. 41

Adults with an IDPH DNR/POLST are also encouraged to complete a Power of Attorney (PoA). Extreme care should be exercised if the PoA or Surrogate wishes to reverse the direction of care previously established by the patient For example, the patient requested Comfort or Selective Treatment, but the PoA or Surrogate wants Full Treatment Changes to a form should be based on evidence of the patient’s wishes A power of attorney can answer the wide range of questions that are not covered by this form, and can provide consents within the parameters already established by the patient. If the patient has chosen DNR, s/he has planned for the eventuality of a full arrest situation, has discussed this with their physician, and has legally documented their refused of the procedure. The PoA can make new decisions, and must make those decisions in a manner in which the patient would make them for himself or herself. Thus, with evidence of the patient’s refusal, it would take a rather extraordinary set of circumstances where providers could override an informed refusal of a procedure by the patient. With Limited or Comfort interventions, the patient has refused some elements of treatment and again, that refusal should be honored by both providers and a PoA. However, a medical evaluation may provide new evidence, and the PoA can make decisions about those elements of care that the patient has not previously refused. 42

Practitioner Orders for Life-Sustaining Treatment R E D C B A Cardio-Pulmonary Resuscitation (CPR) Medical Interventions Medically Administered Nutrition Documentation of Discussion Signature of Attending Practitioner Reverse Side – Contains More Information and Instructions

Section “E”: Signature of Practitioner
The form can be signed by the (a) attending physician, (b) a licensed resident who has completed at least one year of training, (c) a physician assistant, or (d) an advanced practice nurse. If more than one person shares primary responsibility for the treatment and care of the patient, any of those persons may sign the order. 44

Requirements for a Valid Form
Use White or Pink paper Patient name Resuscitation orders (Section “A”) 3 Signatures Patient or legal representative Witness Practitioner All other information is optional Pink paper is recommended to enhance visibility, but color does not affect validity of form Photocopies and faxes ARE acceptable. 45

Who Can Assist in Preparing the Form?
Best practice suggests use of those trained in the POLST Conversation such as (among others): Physicians Social Workers Nurses Chaplains Care Managers Ethicists Physician Assistants Advance Practice Nurses Find an example of a POLST conversation at: 46

POLST is a Process, Not a Form
The form is a documentation tool. POLST should not be used as a check-box form, or as a replacement for an informed conversation between patients, families and providers to: Identify goals of treatment. Make informed choices. The conversation should be documented in the medical record, along with a copy of the completed IDPH DNR/POLST form. 47

Practitioner Orders for Life-Sustaining Treatment R E D C B A Cardio-Pulmonary Resuscitation (CPR) Medical Interventions Medically Administered Nutrition Documentation of Discussion Signature of Attending Practitioner Reverse Side – More Information and Instructions

Reverse Side: Guidelines and Instructions
Completion of the form is always voluntary. 49

Potential System Concerns
Signing practitioner doesn’t have privileges here Orders still must be translated into specific institutional orders Suggest using “Pt is DNR per IDPH DNR order” and have that order signed by assigned staff attending Our physician has never seen this patient before Law indicates DNR must be honored in all care settings Protected from liability for following an IDPH DNR form in good faith Developing best practices for storing, locating, and transmitting document between care settings Institutions should standardize where the document is located so that it is easily available during an emergency, but also protects the patient’s privacy 50

Can I Use POLST Just as a DNR form?
Yes - Section A (requesting CPR or DNR) is the only required section Cross out other sections and mark “No decisions made” If left blank, boxes could be filled in later, effectively creating a medical order that the practitioner is unaware of or may not agree with Makes it clear that patient did not address the subjects in the other sections – decisions can be made at a later date by creating a new form

What Should I Do with an Older IDPH DNR Form?
Continue to follow older IDPH DNR Forms. Update the older form to the new form when it is feasible. Review the form with the patient or legal representative when a change in the patient’s medical condition, goals, or wishes occurs 52

This presentation for the POLST Illinois Taskforce has been made possible by in-kind and other resources provided by:

THANK YOU! Original presentation developed by Kelly Armstrong, PhD
for the Illinois POLST Taskforce. All images purchased from 123rf.com Contact:

Illinois’s IDPH DNR/POLST Form

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