Clinician Resources for DNR/COLST Orders

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

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. Completing an order that says to “do everything” increases the risk of medical error.

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.

If the patient has a properly completed medical order from another state (MOLST, POLST, etc), that is considered a valid order and must be honored like a VT DNR/COLST.

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

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

Section A of the DNR form allows the order to withhold CPR to be written without consent of the patient or surrogate. To write an order on the basis of medical non-benefit, two clinicians must certify 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.

• Provide the original order to the patient with instructions as to the appropriate means of displaying DNR/COLST order. For example, having a copy on the refrigerator of your home.
• Explain the patient’s responsibility in relation to the DNR/COLST order:
  • To enforce the limitation of treatment, the DNR/COLST order must be easily accessible for EMS in the home, or patients must have a copy of the completed order on their person. DNR/COLST ID jewelry from an approved vendor is a valid substitute for the completed order.
  • Discuss how the order should be displayed to ensure that it is honored (on or in refrigerator, option for DNR ID jewelry).
  • Explain that if the patient does not present to the hospital with the order, a copy of the order scanned into a medical record alone cannot be honored without re-affirming the limitation with the patient or surrogate.
  • Discuss that the patient can always revoke their DNR/COLST order by destroying the order or temporarily not displaying it.

• 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.

For example, a Massachusetts MOLST order could be issued by a Massachusetts licensed clinician for a Vermont patient if the patient was in Massachusetts at the time and followed the Massachusetts process for completing a MOLST order.

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.