Home > Legal > Will and Trust Template > Do Not Resuscitate Template > Vermont Do Not Resuscitate Form > Vermont Do Not Resuscitate Template

Vermont Do Not Resuscitate Form

At Speedy Template, You can download Vermont Do Not Resuscitate Form . There are a few ways to find the forms or templates you need. You can choose forms in your state, use search feature to find the related forms. At the end of each page, there is "Download" button for the forms you are looking form if the forms don't display properly on the page, the Word or Excel or PDF files should give you a better reivew of the page.

Vermont Do Not Resuscitate Form
Vermont Do Not Resuscitate Form
Completing DNR/COLST
The DNR/COLST form must be completed and signed by a health care clinician based on patient preferences
and medical indications. A clinician is defined as a medical doctor, osteopathic physician, advance practice
registered nurse or physician assistant. 18 V.S.A. § 9701(4). Verbal orders are acceptable with follow-up
signature by the clinician in accordance with facility/community policy.
Photocopies and Faxes of signed COLST forms are legal and valid; use of original is encouraged.
Special requirements for completing the DNR section of COLST (18 V.S.A. §9708)
A DNR order may be written on the basis of either informed consent or futility. Complete section A-2 for
informed consent; Section A-3 for futility.
An order based on informed consent must include the name of the individual giving informed consent.
An order based on futility must include a certification by the clinician and a second clinician that resuscitation
would not prevent the imminent death of the patient, should the patient experience cardiopulmonary arrest.
If patient is in a health care facility, the clinician must certify that the facility’s DNR policy has been followed
The clinician may authorize the issuance of a DNR identification to the patient
Clinician must certify that clinician has consulted or made an attempt to consult with the patient, and the
patient’s agent or guardian.
Using DNR Order - Section A CPR/DNR - 18 V.S.A. § 9708(c)
A DNR Order (Section A of the DNR/COLST form) only precludes efforts to resuscitate in the event of
cardiopulmonary arrest and does not affect other therapeutic interventions that may be appropriate for the
patient. (Sections B through H of the COLST Form address other interventions.)
Health care professionals, health care facilities, and residential care facilities must honor a DNR order or a DNR
Identification unless the professional or facility believes in good faith, after consultation with the patient, agent
or guardian, where possible and appropriate
o that the patient wishes to have the DNR Order revoked if the Order is based on informed consent, or
o that the patient with the DNR identification or order is not the individual for whom the DNR order was
Documentation of basis for belief in medical record is required.
Using COLST (Sections B through H)
Any section of COLST not completed indicates that the COLST order does not address that topic. It may be
addressed in a patient’s advance directive, or in other parts of the medical record.
Oral fluids and nutrition must always be offered if medically feasible.
When comfort cannot be achieved in the current setting, the person, including someone with “comfort measures
only”, may be transferred to a setting able to provide comfort.
Treatment of dehydration is a measure that may prolong life. For a patient who desires IV fluids the order
should indicate “Limited Interventions” or Full Treatment.”
A patient with or without capacity, or another person authorized to provide consent, may revoke the COLST
order at any time and request alternative treatment. Exceptions may apply. See, 18 V.S.A. § 9707(h) or 18
V.S.A. § 9707(g).
Photocopies and faxes of signed DNR/COLST forms are legal and valid; use of original is encouraged.
Reviewing DNR/COLST
This form should be reviewed periodically and a new form completed if necessary when:
1. The patient is transferred from one care setting or care level to another, or
2. There is a substantial change in the patient’s health status, or
3. The patient’s treatment preferences change, or
4. At least annually, but more frequently in residential or inpatient settings.
To void this form or a part of it, draw a line through each page or section to be voided and write “VOID” in large
Vermont Do Not Resuscitate Form