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North Dakota Do Not Resuscitate (DNR) Order Form

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North Dakota Do Not Resuscitate (DNR) Order Form

Updated July 19, 2023

North Dakota do not resuscitate (DNR) order form is used to inform medical personnel that a patient does not wish to receive cardiopulmonary resuscitation (CPR). This type of order is often requested by patients suffering from end-stage medical conditions that, at the time their breathing or heart stops, would rather die naturally than have their life restored through invasive and painful resuscitation methods. A DNR order can be obtained from the patient’s doctor or other authorized health care providers.

North Dakota has recently adopted the Physician Orders for Life-Sustaining Treatment (POLST) program allowing residents to specify their desired health treatments for serious illnesses and end-stage medical conditions. Like a DNR order, a POLST form will help medical personnel determine what procedures shall be executed when the patient experiences cardiac or respiratory arrest. However, a POLST also provides instructions to be implemented when the patient still has a pulse or is still breathing.

Note: The form available below is a POLST form and not a DNR order. Before completing the form, the patient’s doctor should be contacted and notified of the request.

Laws § 23-06.5

Required to Sign (POLST) – MD/DO/APRN/PA, and patient (or representative).

How to Write

Step 1 – Download the North Dakota POLST form in PDF.

Step 2 – Begin by entering the patient’s last name, first/middle name, and their date of birth (mm/dd/yyyy format).

Step 3 – In section A, select one (1) of the two (2) options to indicate whether or not the patient wishes to receive CPR in the event of cardiopulmonary arrest.

The first option should be selected if the patient does want to be resuscitated.

Select the second option if the patient does not want to be resuscitated.

Step 4 – Select one (1) of the three (3) checkboxes in section B to describe the treatments the patient desires when they are not in cardiopulmonary arrest (i.e., when they have a pulse or are breathing).

Select “COMFORT MEASURES ONLY” if the patient desires general treatments which relieve pain and suffering such as oxygen and oral suction. Furthermore, you can request additional treatments by selecting any of the three (3) remaining boxes. The treatments are as follows:

  • Avoid calling 911 (provide alternate phone number)
  • Do not transport patient to ER
  • Do not admit patient to the hospital from ER

Select “LIMIT INTERVENTIONS AND TREAT REVERSIBLE CONDITIONS” if the patient would like to receive treatments for new or reversible illnesses, injuries, or non-life threatening chronic conditions. This option includes the treatments mentioned in Comfort-Measures Only plus additional treatments such as IV fluids, antibiotics, and non-invasive positive airway pressure.

The final option, “FULL TREATMENT,” should be selected if the patient desires all appropriate medical and surgical treatments to support the patient’s life. This includes intensive care and transfers to the hospital if necessary.

Step 5 – Complete section B by specifying any additional orders the patient requires when they are not experiencing cardiopulmonary arrest.

Step 6 – In section C, select one (1) of the following options to specify the patient’s desired method of administration of artificial nutrition and fluids (if any):

  • No artificial nutrition by tube
  • Defined trial period of artificial nutrition by tube
  • Artificial nutrition and hydration unless no benefit is gained
  • Long-term artificial nutrition by tube

Enter any additional orders in the remaining space.

Step 7 – The options available in section D are used to record the discussion which led to the execution of the POLST form.

Select “Patient” if the patient requested the POLST under their own volition.

If the patient does not have the capacity to execute the POLST order, describe how the form was requested by choosing one (1) of the options on the right. Below the options, enter the name of the health care agent/legal representative and describe their relationship to the patient.

Step 8 – In section E, the patient or health care agent/legal representative must provide their signature and enter the date they signed the document.

Step 9 – Section F must be completed by the physician (or other health care provider) to confirm that the medical orders are consistent with conditions and preferences of the patient. The physician must provide the following:

  • Printed name
  • Phone number
  • License number
  • Signature
  • Date of signing
  • Time of signing

Step 10 – Proceed to page (2) of the POLST form and enter the following information in the empty spaces:

  • Patient’s name
  • Patient’s date of birth
  • Health care agent/legal representative information
    • Name
    • Relationship to patient
    • Phone number
    • Address
  • Form preparer information
    • Title
    • Phone number
    • Date prepared