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Step 3

Set Your Limits

Considering Medical Orders to Limit Treatment

Some seriously ill or dying people do not want certain medical procedures or treatments at the end of life. Others do not want to be taken to a hospital if a medical issue arises, or be given aggressive treatment. An advance directive (AD) alone may not be enough to ensure that wishes to limit treatment will be honored because ADs are not recognized by emergency medical personnel and first responders.

A Do-not-rescuscitate (DNR)/Clinician orders for life-sustaining treatment (COLST) order is necessary 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 a shared decision-making process between a patient (or their agent, guardian or surrogate, if the patient lacks decision-making capacity) and their clinician (physician, physician assistant or nurse practitioner). They are based on an individual’s current medical condition and their goals and values.

DNR/COLST orders address the following medical treatments:

  • Cardiopulmonary resuscitation (CPR)
  • Breathing machines (intubation and ventilation)
  • Artificial feeding and fluids
  • Going to the hospital
  • Antibiotics
  • Other medical treatments

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

CharacteristicsDNR/COLSTAdvance Directives
PopulationFor the seriously illAll adults with capacity
TimeframeCurrent careFuture care
Who completesClinicians (MD/DO, PA, ARPNP)Patients
Resulting documentMedical Orders (DNR/COLST)Advance Directive
Health Care Agent, Guardian or Surrogate roleCan engage in discussion if patient lacks capacity; consent/withhold consentCannot complete or revise
PortabilityProvider responsibilityPatient/family responsibility
Periodic reviewProvider responsibilityPatient/family responsibility

Bomba, PA and Black, J. The POLST: an improvement over traditional advance directives. Cleveland Clinic Journal of Medicine, 2012; 79 (7): 457-64.

FAQs for Patients and Families

Who should consider a DNR/COLST order?
  • 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
What should someone think about when making decisions about life-sustaining treatment?
  • 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?
How frequently does a DNR/COLST order need to be updated?

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
Is a DNR order from before July 1, 2011 still valid?

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

Who can consent for a DNR/COLST order?

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.

Can a patient revoke a DNR/COLST order?

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

Can a DNR order be written without consent?

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.

Will a Vermont DNR/COLST order be honored in another state?

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 I have a DNR/COLST order do I need to carry it with me?

If you want your DNR order to be honored, you must either have the signed order with you or obtain a Vermont DNR identification. Wearable DNR identifications can be obtained from vendors who have been approved by the Vermont Department of Health.

Will a DNR identification be honored the same as my DNR/COLST form?

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.

Should my DNR/COLST order be registered with the Vermont Advance Directive Registry?

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

Who should have a copy of my DNR/COLST order?

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.

Where should my DNR/COLST order be kept in my home?

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.

FAQs for Providers and Facilities

Should a patient's code status be documented on the DNR/COLST form even if they are a full code?

Consent for CPR is presumed 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 to document a DNR order or other limitation of treatment.

If someone has a medical order to limit treatment, does that order need to be documented on the Vermont DNR/COLST form?

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.

Does someone need a DNR/COLST order for transport by ambulance if they are a full code?

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

Who can complete and sign a DNR/COLST order?

DNR/COLST orders require informed consent. Therefore, they must be completed by a clinician (medical doctor, osteopathic physician, 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.

Is the original order required or is a copy permitted?

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

Who can consent for a DNR/COLST order?

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.

Can a DNR order be written without consent?

Section A-3 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.

Is it permissible to not honor a DNR/COLST order?

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.

Do I need to honor another state's order?

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.

What is a clinician's responsibility once a DNR/COLST is completed?
  • Place a copy of the completed DNR/COLST in the patient’s medical record
  • Issue a DNR identification (bracelet, necklace, anklet) to the patient
  • Provide instructions to the patient as to the appropriate means of displaying DNR/COLST order. For example, having a copy on the refrigerator of your home.
What is a facility's responsibility for DNR/COLST orders?
  • 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

 

Can a patient revoke an order that is written based on futility?

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.

Can a non-Vermont licensed physician write a DNR/COLST order for a Vermont patient?

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.

How frequently should a clinician update a patient's DNR/COLST order?

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
Where can I find the statutory and regulatory requirements for DNR/COLST orders?

Download the Brochure for Considering Medical Orders to Limit Treatment