Set Your Limits

• People with serious, advanced, or life-limiting medical conditions
• People who are certain that they want to avoid life-sustaining treatments
• People who might die within the next year

• Will the treatment help?
• Is recovery possible? If so, what will life be like afterward?
• Do the potential benefits of the treatment outweigh the burdens?
• How much are you willing to go through for the possibility of gaining more time?

There is no requirement for regular updating. It is recommended that the form be updated periodically, and a new form completed if necessary, when:

• the patient is transferred from one care setting or care level to another; or
• there is a substantial change in the patient’s health status; or
• the patient’s goals and/or treatment preferences have changed

Yes, if the order complied with the statutory requirements in effect at the time the order was completed.

A patient with decision-making capacity can consent for their own DNR/COLST order. If a patient lacks capacity, a health care agent, guardian (with authority for medical decisions and appropriate oversight), or surrogate (following statutory requirements) can give consent.

Yes, if the order was written based on informed consent it can be revoked.

Yes, it can happen without consent when the patient’s clinician and one other clinician certify that resuscitation would not prevent the imminent death of the patient, should the patient experience cardiopulmonary arrest.

Because the laws in each state vary, there is no automatic guarantee that a DNR/COLST will be respected in every state. That said, a signed DNR/COLST order carries moral weight surrounding an individual’s priorities for end-of-life treatments.

If you want your DNR order to be honored, you must either have the signed order with you or obtain a Vermont approved DNR identification (bracelet, necklace, etc.). Wearable DNR identifications can be obtained from vendors who have been approved by the Vermont Department of Health. Approved DNR Identification vendors require that you submit a copy of your completed DNR/COLST order with your request, which will be kept on file with the vendor to ensure that your identification is connected to a properly completed order. DNR Identification cannot be obtained without a properly completed order on file.

Yes. The presence of a valid DNR Identification that meets the minimum requirements shall be honored by all providers, including Emergency Medical Service providers, the same as a signed, written DNR/COLST order.

A DNR Identification that does not conform with the requirements outlined by the Vermont Department of Health shall not be recognized as a valid DNR Identification and shall not be honored by providers.

No, the Vermont Advance Directive Registry is only for advance directives.

You should keep the original and copies should be given to your physician, the hospital where you receive care, and your health care agent. You may also give a copy to friends or family members that you think should know this information.

The general consensus among first responders is that these orders should be kept on your refrigerator. You may want to check with your local emergency medical system to see where they recommend that you keep your order in your town or community.

No. Full code is the standard of care absent a DNR order. Therefore, anyone who does not have a DNR order is a full code. The DNR/COLST form is required in an outpatient setting ONLY to document a DNR order or other limitation of treatment.

Yes, in an outpatient setting all out-of-hospital DNR/COLST orders must be documented on the Vermont Department of Health’s DNR/COLST form. In the inpatient setting, health care facilities or residential care facilities may document DNR/COLST orders in a patient’s medical record in a facility-specific manner when the patient is in their care.

No, the standard of care is that absent a DNR/COLST order indicating a withholding of CPR an individual is presumed full code.

DNR/COLST orders require informed consent. Therefore, they must be completed by a clinician (medical doctor, osteopathic physician, advanced practice registered nurse, or physician assistant) based on the patient’s current medical condition and their goals and values. Verbal orders are acceptable with follow up signature from the physician in accordance with the facility’s policy.

Photocopies and faxes of properly completed and signed DNR/COLST forms are legal and valid.

A patient with decision-making capacity can consent for their own DNR/COLST order. If a patient lacks capacity, a health care agent, guardian (with authority for medical decisions and appropriate oversight), or surrogate (following statutory requirements) can give consent. Signature by the person who is giving consent is not required.

Section A of the DNR form allows the order to withhold CPR to be written without consent when two clinicians have certified that CPR would not prevent the imminent death of the patient, should the patient experience a cardiopulmonary arrest.

All health care providers, including emergency medical personnel and staff of health care facilities shall honor a DNR order unless:

• the provider or facility believes in good faith that the patient is not the person identified in the DNR order; or
• the patient wishes to have the DNR order revoked

If a DNR order is not honored, the health care provider must document the basis for that decision in the patient’s medical record.

Yes, according to Vermont law (Section 18 V.S.A. § 9708), a healthcare provider shall honor in good faith an out-of-state DNR order, order for life-sustaining treatment, or out-of-state DNR identification if there is no reason to believe that what has been presented is invalid.

• Adopt a DNR protocol ensuring that DNR orders are issued, revoked and handled according to the same standards and processes for each patient at that facility.
• Provide a copy of the facility’s protocol upon request
• Document DNR orders in the patient’s medical record in a facility-specific manner when a patient is in their care

No. If consent has not been given and the order is written on the basis of medical non-benefit (futility), then a patient (their agent, surrogate, guardian) cannot revoke that order. While every patient has the right to refuse any proposed treatment, this right of refusal does not translate into a right to demand a treatment that a clinician knows will not work.

Yes. Vermont law allows a clinician to write these orders so long as the clinician who treated the patient outside of Vermont held a valid license to practice in the state in which the patient was located at the time the DNR/COLST was issued.

There is no requirement for regular updating. It is recommended that the form be reviewed periodically, and a new form completed if necessary, when:

• the patient is transferred from one care setting or care level to another; or
• there is a substantial change in the patient’s health status; or
• the patient’s goals and/or treatment preferences have changed

DNR/COLST section of the Advance Directive statute

Advance Directive Rules (see sections 8, 9 and 10)

Yes, documented clinical signature of a verbal order on the DNR/COLST form is considered acceptable and will be honored by EMS. To document a clinician’s verbal order signature on the DNR/COLST form, the following is required:

• The patient’s nurse or social worker must print the clinician’s name in Section A6 for DNR and/or Section H for COLST and write “Verbal Order” on the clinician signature line.
• The nurse or social worker documenting the verbal order must also sign and date the form.
• A duplicate DNR/COLST must be completed and sent to the clinician for an original signature.
• At the earliest convenience, the order with the original signature must be returned to the patient to replace the previously documented verbal order.