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Vermont Do Not Resuscitate Form

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Vermont Do Not Resuscitate Form Page 2
Vermont Do Not Resuscitate Form
HIPAA PERMITS DISCLOSURE OF COLST TO OTHER HEALTH CARE PROFESSIONALS AS NECESSARY
Patient Last Name
Patient First/Middle Initial
DNR/COLST
CLINICIAN
ORDERS
for DNR/CPR and OTHER LIFE SUSTAINING TREATMENT
FIRST follow these orders, THEN contact Clinician.
Date of Birth
(If patient/resident has no pulse and/or no respirations)
A
DO NOT RESUSCITATE (DNR)
DNR/Do Not Attempt Resuscitation
(Allow Natural Death)
CARDIOPULMONARY RESUSCITATION (CPR)
CPR/Attempt Resuscitation
For patient who is breathing and/or has a pulse, GO TO SECTION B – G, PAGE 2 FOR OTHER
INSTRUCTIONS. CLINICIANS MUST COMPLETE SECTIONS A-1 THROUGH A-5
A-1 Basis for DNR Order
Informed Consent - Complete Section A-2
Futility - Complete Section A-3
A-2 Informed Consent
Informed Consent for this DO NOT RESUSCITATE (DNR) Order has been obtained from:
______________________________________________ _______________________________________
Name of Person Giving Informed Consent (Can be Patient) Relationship to Patient (Write “self” if Patient)
________________________________________________
Signature (If Available)
A-3 Futility (required if no consent)
I have determined that resuscitation would not prevent the imminent death of this patient should the patient
experience cardiopulmonary arrest. Another clinician has also so determined:
____________________________________________________ _______________________________________
Name of Other Clinician Making this Determination (Print here) Signature of Other Clinician
Dated:______________________
A-4 Facility DNR Protocol (required if applicable)
This patient is
is not
in a health care facility or a residential care facility.
Name of Facility:________________________________________________________
If this patient is in a health care facility or a residential care facility, the requirements of the facility’s DNR protocol have
been met.__________ (Initial here if protocol requirements have been met.)
A-5 DNR Identification (optional)
I have authorized issuance of a DNR Identification (ID) to this patient. Form of ID:____________________________
Certification and
signature for DNR
A-6 Clinician Certifications and Signature for CPR/DNR (required)
I have consulted, or made an effort to consult with the patient and the patient’s agent or guardian.
Patient’s Agent or Guardian_____________________________Address or Phone_____________________________
I certify that I am the clinician for the above patient, and I certify that the above statements are true.
_________________________________________ _________________________________________
Signature of Clinician Printed Name of Clinician
Dated:______________________
GIVE COPY TO PATIENT AND REPRESENTATIVE
SEND FORM WITH PATIENT WHENEVER TRANSFERRED OR DISCHARGED
Vermont Do Not Resuscitate Form