NHDD 2023: Start planning today! Vermont Advance Directive Week: April 9-16 | National Health Care Decisions Day: April 16
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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.
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.
|Population||For the seriously ill||All adults with capacity|
|Timeframe||Current care||Future care|
|Who completes||Clinicians (MD/DO, PA, ARPNP)||Patients|
|Resulting document||Medical Orders (DNR/COLST)||Advance Directive|
|Health Care Agent, Guardian or Surrogate role||Can engage in discussion if patient lacks capacity; consent/withhold consent||Cannot complete or revise|
|Portability||Provider responsibility||Patient/family responsibility|
|Periodic review||Provider responsibility||Patient/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.
There is no requirement for regular updating. It is recommended that the form be updated periodically, and a new form completed if necessary, when:
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 DNR identification. Wearable DNR identifications can be obtained from vendors who have been approved by the Vermont Department of Health.
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.
On June 1, 2022, a new and improved Vermont DNR/COLST form takes effect. Watch the video below to learn more about how the form was updated and the best practices for completing these orders with patients.
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:
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.
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:
DNR/COLST section of the Advance Directive statute
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: