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Vermont Do Not Resuscitate (DNR) Order Form

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Vermont Do Not Resuscitate (DNR) Order Form

Updated July 19, 2023

The Vermont do not resuscitate (DNR) order form details the end-of-life resuscitative treatments which should be applied to a patient when they experience respiratory or cardiac arrest. The DNR order instructs emergency health care providers to withhold the administration of cardiopulmonary resuscitation (CPR) as desired by the patient or their legal representative. Furthermore, the form may be used to define the medical interventions necessary to maintain the patient’s health and comfort when they can still breathe or when their heart is still beating (e.g., feeding tube, fluids, antibiotics).

Note: The patient’s clinician must be consulted when preparing the document.

Laws – § 9708 and § 9709

Required to Sign – MD/DO/APRN/PA, and patient (if able to sign) or their representative.

How to Write

Step 1 – Download the Vermont DNR order form in PDF.

Step 2 – Proceed to page (2) of the DNR order form and input the patient’s name and date of birth in the first two (2) spaces.

Step 3 – Using the empty fields available to the right on the heading, enter the patient’s last name, first/middle initial, and date of birth.

Step 4 – In section A, you must specify whether or not the patient shall be resuscitated if they do not have a pulse or cannot breathe. Only one (1) of the available options may be selected.

Choose the box on the left if the patient should not be resuscitated (allow for natural death).

Select the box on the right if the patient should be resuscitated during a medical emergency.

Step 5 – The DNR order should be written with the informed consent of the patient (or agent, surrogate, guardian). However, if informed consent cannot be obtained, a second authorized clinician must review the order and certify the document.

If the patient or their representative consents to the issuance of the DNR order, they must enter the following information in section A-2:

  • Name
  • Relationship to patient (if patient, write “self”)
  • Signature (if possible)

If informed consent cannot be obtained, the DNR order must be reviewed by two (2) authorized clinicians in order to confirm that resuscitative procedures would not benefit the patient. The attending clinician must verify this information by selecting the checkbox in section A-3. Also in section A-3, the second clinician must enter their name, provide their signature, and date the document.

Step 6 – In section A-4, specify whether the patient is currently placed in a health care or residential care facility; select the applicable box and enter the name of the facility in the space provided. If the patient is indeed in a health care or residential care facility, the attending clinician must supply their initials in order to confirm that the requirements of the facility’s DNR protocol have been met.

Step 7 – If the attending clinician has issued the patient a form of DNR identification, enter the type of ID in section A-5.

Step 8 – The attending clinician must certify the DNR order by filling out section A-6. In doing so, the clinician confirms that they have consulted, or made an effort to consult, the patient and their agent or guardian. The clinician must enter the name of the patient’s agent or guardian and their address or phone number. Below that, the clinician must provide their signature, print their name, and enter the date.

Step 9 – Continue to page (3) of the DNR order form and, at the top of the page, enter the patient’s name followed by their date of birth.

Step 10 – In section B, describe the intubation and mechanical ventilation procedures which shall be administered to the patient (if any) in the event of progressive or impending pulmonary failure without acute cardiopulmonary arrest. Select one of the following options:

  • Do not intubate/multi-lumen airway (DNI)
  • Trial period of intubation/multi-lumen airway and ventilation
  • Intubation/multi-lumen airway and long-term mechanical ventilation (if needed)

Step 11 – Section C contains information relating to whether or not the patient should be transferred to the hospital. Select the first box if the patient should not be transferred to the hospital unless their comfort needs cannot be met at their current location or if severe symptoms cannot be controlled. Alternatively, select the second box if transfers to the hospital are permitted.

Step 12 – In section D, choose one (1) of the following options to indicate the preferred level of antibiotics:

  • No antibiotics (use other means to treat symptoms)
  • Determine use or limitation of antibiotics when infection occurs
  • Use antibiotics

Step 13 – Section E contains several options allowing you to specify the preferred method of artificially administered nutrition and parenteral nutrition or hydration.

Select one (1) of the following options to indicate the preferred method of artificially administered nutrition:

  • No feeding tube
  • Trial period of feeding tube (describe goal)
  • Long-term feeding tube

Step 14 – Next, in section E, indicate the preferred method of parenteral nutrition or hydration. The available options are as follows (select one (1) box only):

  • No parenteral nutrition or hydration
  • Trial period of parenteral nutrition or hydration (describe goal)
  • Long-term parenteral nutrition or hydration

Step 15 – There are three (3) options in section F which allow you to specify the preferred medical interventions to be applied when the patient can still breathe or has a pulse. Only one (1) of the boxes may be selected.

Select the first box, “COMFORT MEASURES ONLY,” if general care to alleviate pain and suffering shall be applied to the patient.

Select the second box, “LIMITED ADDITIONAL INTERVENTIONS,” if the patient should receive medical treatments and IV fluids. This option includes the interventions defined in Comfort Measures Only.

Choose the final box, “FULL TREATMENT,” if the patient should be treated with the care available in both of the aforementioned medical interventions. Full Treatment also includes the application of defibrillation and intensive care if required.

Step 16 – Enter any additional instructions in the blank space found in section G.

Step 17 – Continue to page (4) and enter the patient’s name and date of birth at the top of the page.

Step 18 – The patient or their representative must indicate their consent to sections B through G of the DNR order form. The individual must enter their name, relationship to the patient (if patient is signing, write “self”), and their signature.

Step 19 – Continue filling out section H by having the attending clinician supply their signature, printed name, and the date.

Step 20 – The following information must be provided in order to complete section H:

  • Name of clinician
  • Signature of clinician
  • Phone number of clinician
  • Signature of person giving consent (if possible)
  • Date

Step 21 – Below the “Other Contact Information” heading, you may optionally enter the following contact details:

  • Name of guardian, agent, or other contact
  • Contact’s relationship to patient
  • Contact’s phone number
  • Name of health care professional preparing the DNR order form
  • Preparer title/facility
  • Phone number of preparer
  • Date prepared

Step 22 – The remaining spaces of the DNR order form should only be used be used when the under the following circumstances:

  • Change of patient’s desired treatments
  • Change in patient’s health
  • Patient is transferred to another care setting/level of care
  • Annual review or more frequently if the patient is in a residential or inpatient setting

If any of the above circumstances apply, a health care professional must review the DNR order to ensure that the form is still applicable to the patient’s health status. After the document has been reviewed, the individual must enter the following information in the remaining spaces of the form:

  • Review date
  • Name of reviewer
  • Location of review
  • Review outcome