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Utah Do Not Resuscitate Form


Utah Do Not Resuscitate Form
Utah Do Not Resuscitate Form
Utah Department of Health
Bureau of Health Facility Licensing, Certification and Resident Assessment
Physician Order for Life Sustaining Treatment
Utah Life with Dignity Order
Version 2 – 9/09
State of Utah Rule R432-31
(http://health.utah.gov/hflcra/forms.asp)
This is a physician order sheet based on patient wishes
and medical indications for life-sustaining treatment. Place
this order in a prominently visible part of the patient’s
record. Both the patient and the physician must sign this
order (two physicians must sign if the patient is a minor
child). When the patient’s condition makes this order
applicable, first follow this order, and then, if necessary,
contact the signing physician.
Physician’s Name:
Physician’s Phone:
Last Name of Patient:
First Name/Middle Initial:
Date of Birth:
Effective Date of this Order:
(IF NOTHING IN A SECTION IS CHECKED, CAREGIVERS SHOULD PROVIDE THE FULLEST TREATMENT DESCRIBED IN THAT
SECTION UNLESS THAT TREATMENT DIRECTLY CONFLICTS WITH A TREATMENT CHECKED IN ANOTHER SECTION)
Section A
Check one
Treatment options when the patient has no pulse and is not breathing:
___ Attempt to resuscitate ____ Do not attempt or continue any resuscitation (DNR)
Other instructions or clarification:____________________________________________________
_________________________________________________________________
_________________________________________________________________
Section B
Check one
Treatment options when the patient has a pulse and is breathing:
___ Comfort measures only: Oral and body hygiene; reasonable efforts to offer food and fluids
orally; medication, oxygen, positioning, warmth, and other measures to relieve pain and suffering.
Provide privacy and respect for the dignity and humanity of the patient. Transfer to hospital only if
comfort measures can no longer be effectively managed at current setting.
___ Limited additional interventions: Includes care above. May also include suction, treatment of
airway obstruction, bag/valve/mask ventilation, monitoring of cardiac rhythm, medications, IV fluids.
Transfer to hospital if indicated, but no endotracheal intubation or long-term life support
measures.
Other instructions or clarification:_________________________________________________
_________________________________________________________________
___ Full treatment
: Includes all care above plus endotracheal intubation, defibrillation/cardioversion,
and any other life sustaining care required.
If necessary, transfer to (hospital name): _____________________________________________
Other Instructions or clarification:____________________________________________________
_________________________________________________________________
_________________________________________________________________
Section C
Check all
that apply
Antibiotics: (Comfort measures are always provided)
___ No antibiotics
___ Antibiotics may be administered
Other Instructions or clarification:________________________________________________
______________________________________________________________
Utah Do Not Resuscitate Form
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