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Minnesota Do Not Resuscitate (DNR) Order Form

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The Minnesota do not resuscitate (DNR or DNAR) order form and the Physician Orders for Life-Sustaining Treatment (POLST) form, are both documents which translate the wishes outlined in an individual’s health care directive into a medical order. These forms communicate the end-of-life treatments that an individual will allow, including life-sustaining care and cardiopulmonary resuscitation (CPR). A DNR order specifically orders that if the subject’s heartbeat or breathing stops, CPR should not be administered. A POLST form covers many other life-sustaining or symptom-reducing procedures and may be used in addition to or instead of a DNR order. If a patient is in critical condition, they may request a DNR order or a POLST form from their physician. Once issued, the document will be kept in the patient’s medical record to ensure that medical personnel knows how the patient wishes to be treated. The patient or their representative may revoke the DNR order and/or POLST form at any juncture by informing their health care provider that they wish it to be revoked.

LawsChapter 145C

Required to Sign – Patient (or representative) and the attending physician.

How to Write

Step 1 – Download the Minnesota POLST Form.

Step 2 – Enter the full name and date of birth of the patient, along with the name and phone number of their primary medical provider.

Step 3 – In Section A, you must indicate whether or not a DNR order should be issued.

Step 4 – Beneath “Medical Treatments,” you will need to select what level of treatment the patient should receive if they have a pulse and/or are breathing.

Step 5 – In Section C, the individuals who took part in this decision should be indicated by checking the appropriate boxes. Below that, supply the signature and name of the patient or their surrogate, along with their relationship to the patient and phone number.

Step 6 – Supply the attending physician’s name, license type, phone number, and signature, as well as the date.

Step 7 – Enter the patient’s name at the top of the second page of the POLST form.

Step 8 – Indicate what types of administration for nutrition and antibiotics will be permitted in treating the patient. Below that, provide any additional instructions that have not been covered in the document.

Step 9 – As the health care provider preparing the document, provide your name, title, and phone number, along with the date that the document was prepared.


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