Vermont DNR/COLST Orders
Considering Medical Orders to Limit Treatment
Do-not-resuscitate (DNR)/Clinician orders for life-sustaining treatment (COLST) orders are used to ensure that a preference to limit treatment will be honored across all care settings – particularly in an emergency. DNR/COLST orders are the outcome of informed consent conversation between a patient (or their agent, guardian*, or informal surrogate, if the patient lacks decision-making capacity) and their clinician (MD, DO, PA, APRN/NP). They are based on an individual’s current medical condition and their goals and values.
Court-appointed guardians require additional approval from the probate court to consent for DNR/COLST orders. Learn more about medical guardianship.
Some people do not want certain medical procedures or treatments under any circumstances. An advance directive alone is not enough to ensure that limitations of treatment will be honored in all settings because advance directives cannot be recognized by emergency medical personnel and first responders. Only a DNR/COLST order will prevent CPR or other interventions from being administered in an emergency situation.
DNR/COLST orders address the following medical treatments:
- Cardiopulmonary resuscitation (CPR)
- Breathing machines (intubation and ventilation)
- Artificial feeding and fluids
- General guidelines for medical treatment
- Antibiotics
If you are certain that you would not want one or more of these treatments regardless of the medical situation you are in, it is important to have a discussion with your clinician to see if a DNR/COLST order is right for you.
Differences Between DNR/COLST and Advance Directives
| Characteristics | DNR/COLST Orders | Advance Directives |
|---|---|---|
| Who should consider completing this document? | For the seriously ill | For all adults with capacity |
| When does the document apply? | Directs current care | Directs future care |
| Who completes the document? | Clinicians (MD/DO, PA, APRN) after conversation with patient | Patients can complete independently |
| Resulting document | Portable Medical Order (DNR/COLST) | Advance Directive |
| Role of the health care agent, guardian or informal surrogate | Can discuss with clinician if patient lacks capacity & consent/withhold consent for the medical orders *Guardians MUST seek review from probate court prior to consent.* | Cannot complete or revise |
| Portability (who keeps track of the document?) | Patient/surrogate responsibility | Patient/surrogate responsibility |
| Who should review the document? | Provider responsibility - review annually when meeting with the patient/surrogate | Patient responsibility |
Bomba, PA and Black, J. The POLST: an improvement over traditional advance directives. Cleveland Clinic Journal of Medicine, 2012; 79 (7): 457-64.
What should I do with my completed DNR/COLST order?
If you want your DNR order to be honored, you must either have the signed order with you or obtain a piece of Vermont-approved DNR identification jewelry. In your home, a copy of the order should be displayed on or in the refrigerator. You can call your local EMS department to get their recommendation on where the first response teams in your community check for these documents.
If you live in an independent living facility, skilled nursing facility, or other residential care setting, check with your facility administrator to find out where medical orders should be displayed in your residence.
Wearable DNR identification jewelry (bracelet, necklace, etc.) 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.
Approved DNR/COLST identification vendors are:
These vendors keep a copy of your order on file when you order a piece of ID jewelry, so that first responders can rely on the accuracy of their product.
FAQs for Patients and Families
- 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 reviewed with a clinician 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, prior orders are valid if the order complied with the statutory requirements in effect at the time it 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. Orders written on the basis of medical non-benefit cannot 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 are traveling to another state with your DNR/COLST order, check the laws in that state to find out what you will need to have the order honored.
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 health care agent and alternate agent. If you reside in a facility, the facility should also have a copy on file. You may also give a copy to friends or family members that you think should know this information.
If you would like your order to be honored at a hospital admission, you must bring it with you to the hospital.
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.
Taking Steps Series
Step 3: Considering Medical Orders to Limit Treatment
