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In the state of Vermont, individuals have the option to make crucial decisions about their healthcare, especially in terms of life-sustaining treatments through the Do Not Resuscitate (DNR) Order form. This document serves as a critical component of advance directives, allowing persons to refuse certain types of emergency medical interventions, such as CPR (cardiopulmonary resuscitation), in the event they suffer from a life-threatening illness or injury and are unable to communicate their wishes. The DNR order, which must be signed by both the patient and their physician, highlights the importance of respecting patients' autonomy and adhering to their healthcare preferences. By making such preferences legally recognized, the form also aids healthcare providers in understanding and implementing patients' decisions, thus preventing unnecessary or undesired medical interventions that may not align with the patient's quality of life expectations. The existence of the Vermont DNR Order form underscores the balance between medical ethics and legal considerations in healthcare, ensuring that the rights of the patient are preserved while providing clear guidance for healthcare professionals.

Preview - Vermont Do Not Resuscitate Order Form

Vermont Do Not Resuscitate Order Template

This document serves as a Do Not Resuscitate (DNR) Order in accordance with the Vermont Patient Choice at the End of Life Act. It is designed to communicate the wishes of individuals who, due to medical conditions, choose not to have resuscitation attempted in the event of respiratory or cardiac arrest. Please complete all sections with accurate information to ensure your wishes are clearly understood.

Patient Information

  • Full Name: ___________________________________________
  • Date of Birth: ________________________________________
  • Address: _____________________________________________
  • City: __________________ State: VT Zip Code: ____________
  • Phone Number: ________________________________________

Medical Information

  • Primary Physician: _____________________________________
  • Physician Phone Number: ________________________________
  • Primary Diagnosis: _____________________________________
  • Secondary Diagnosis (if applicable): _____________________

DNR Order

This DNR Order reflects the expressed wishes of the above-named patient not to have cardiopulmonary resuscitation (CPR) attempted in the event of cardiac or respiratory arrest. By signing this document, the patient acknowledges understanding the full implications of this decision.

Signature Section

By signing below, I confirm that I am fully informed and aware of the nature and effect of this document and the decision to not receive resuscitation measures in the circumstances described above.

  • Patient's Signature: ___________________________________ Date: ________________
  • If applicable, Legal Guardian's Signature: _______________ Date: ________________

Physician's Verification

This section to be completed by the attending physician who has discussed the full implications of the Do Not Resuscitate Order with the patient or, when applicable, the patient's legal guardian.

  • Physician's Signature: _________________________________ Date: ________________
  • License Number: _______________________________________

This Do Not Resuscitate Order is valid throughout the state of Vermont and must be reviewed annually for continuity of patient care preferences. It is the responsibility of the patient or legal guardian to provide current copies to health care providers.

⇓ PDF File

Document Overview

Fact Detail
1. Purpose The Vermont Do Not Resuscitate (DNR) Order form is designed to inform healthcare professionals not to perform cardiopulmonary resuscitation (CPR) in the event a patient's breathing or heartbeat stops.
2. Applicability This form is applicable to patients across Vermont who choose not to receive CPR in instances of cardiac or respiratory arrest.
3. Governing Law The form is governed by Vermont's Patient Choice at End of Life laws, which include provisions relating to advance directives and end-of-life decisions.
4. Authority to Sign The form must be signed by the patient, if capable, or otherwise by the patient's legally recognized health care agent or surrogate under Vermont law.
5. Physician's Role A physician or advanced practice registered nurse (APRN) must also sign the form, validating the patient's decision and medical condition warranting the DNR order.
6. Validity and Recognition The DNR order is recognized and valid across the state of Vermont once properly completed and signed.
7. Revocation Patients may revoke the DNR order at any time through a verbal or written statement to their healthcare provider.
8. Emergency Services Notification Patients with a DNR order are encouraged to notify emergency services (e.g., through a File of Life card) to ensure the order is followed in an emergency situation outside of a hospital.

Vermont Do Not Resuscitate Order: Usage Guidelines

Filling out a Vermont Do Not Resuscitate (DNR) Order form is a critical step for those who wish to have their medical preferences known and respected in emergency situations. This document ensures that in the event of a life-threatening condition, medical personnel are informed of your decision not to undergo certain life-saving treatments, such as CPR. Completing this form requires careful consideration and a clear understanding of what each section demands. Below, you'll find straightforward instructions to guide you through the process.

Steps for Filling Out the Vermont DNR Order Form

  1. Gather all necessary information, including the patient's full name, date of birth, and primary care physician's details.
  2. Read the form thoroughly to understand what is being asked. It’s important to understand the implications of a DNR order.
  3. Complete the patient information section, accurately entering your name, date of birth, and other personal details.
  4. Discuss your wishes with a healthcare provider to ensure that a DNR order aligns with your health care goals.
  5. Have the healthcare provider fill out the medical professional section. This part typically requires the healthcare provider's assessment and confirmation that the DNR order is appropriate based on your health status and healthcare preferences.
  6. If applicable, include details of your legal representative or healthcare agent who is authorized to make decisions on your behalf.
  7. Ensure that the form is signed by all required parties—the patient (or their legal representative) and the healthcare provider. The signature is an important legal aspect that validates the form.
  8. Review the completed form for accuracy and completeness. Double-check all entered information to ensure there are no errors.
  9. Make copies of the signed form. Provide a copy to your primary care physician, keep one for your records, and consider giving copies to close family members or friends.

Once the Vermont DNR Order form is completed and properly signed, it becomes an active part of your medical record. It informs healthcare professionals of your decisions regarding resuscitation attempts in emergencies. Remember, this decision can be reviewed and changed at any point, so it’s important to revisit the conversation with your healthcare provider periodically or if your health status changes.

Your Questions, Answered

  1. What is a Vermont Do Not Resuscitate Order form?

    A Vermont Do Not Resuscitate (DNR) Order form is a legal document that instructs healthcare providers not to perform cardiopulmonary resuscitation (CPR) if a patient's breathing stops or if the patient's heart stops beating. It is used by individuals who wish to decline CPR in the event of a cardiac or respiratory arrest, often due to a serious illness which makes the prospect of recovery unlikely and the process of resuscitation more burdensome than beneficial.

  2. Who can request a DNR Order in Vermont?

    In Vermont, a DNR Order can be requested by any competent adult for themselves or for someone they are legally authorized to make healthcare decisions for, such as a minor child or an incapacitated adult. This includes individuals who have a durable power of attorney for healthcare or are a legally appointed guardian.

  3. How do you obtain a DNR Order in Vermont?

    Obtaining a DNR Order in Vermont involves a discussion with a healthcare provider who can assess the individual's health status and understand their wishes regarding CPR. The healthcare provider then completes the DNR Order form based on these wishes. The completed form must be signed by both the healthcare provider and the patient or the patient’s legal representative.

  4. Is a DNR Order permanent?

    No, a DNR Order is not permanent. The individual or their legal representative can cancel or revoke the order at any time, simply by informing their healthcare provider about their change of heart. Additionally, a DNR Order should be reviewed periodically, especially if the individual's health status changes.

  5. Does a DNR Order affect other treatments?

    No, a DNR Order specifically addresses the use of CPR in the event of cardiac or respiratory arrest. It does not impact the provision of other forms of medical care, such as pain management, oxygen, or antibiotics. The focus is solely on the individual's wishes concerning resuscitation efforts.

  6. Can a DNR Order be enforced in different settings?

    Yes, a DNR Order can be enforced in various settings, including at home, in a hospital, or in a nursing care facility in Vermont. It is essential to ensure that the DNR Order is accessible to healthcare providers in these settings. Some individuals may choose to wear a DNR bracelet or carry a card indicating their DNR status for this purpose.

  7. What should you do with the DNR Order once it's completed?

    Once the DNR Order is completed, it’s crucial to keep it in a place where it can easily be found by EMS or healthcare providers. Copies should be given to the patient’s physician, family members, and caregivers. Some individuals also keep a copy on the refrigerator or in a wallet or purse.

  8. Can family members override a DNR Order?

    It can be challenging if family members disagree with the DNR Order, but legally, if the DNR Order has been properly executed, healthcare providers are bound to follow it. It underscores the importance of discussing one's wishes with family members ahead of time to avoid conflicts during a medical crisis.

  9. Is a DNR Order the same as a Living Will?

    No, a DNR Order and a Living Will are not the same. While they both relate to end-of-life decisions, a Living Will is broader and can include a variety of medical directives, including but not limited to resuscitation. A DNR Order is specifically focused on the decision regarding CPR in the event of cardiac or respiratory arrest.

  10. Who should you talk to if you're considering a DNR Order?

    If you’re considering a DNR Order, it’s wise to start by discussing your thoughts and concerns with a healthcare provider who understands your medical history and overall health situation. Additionally, consulting with a legal professional can help ensure that all your directives are correctly documented and legally binding.

Common mistakes

When it comes to filling out the Vermont Do Not Resuscitate (DNR) Order form, accuracy and attention to detail are paramount. A DNR order is a serious and sensitive document that can greatly impact an individual's medical care in critical moments. However, mistakes can happen. Here are six common errors people make when completing their Vermont DNR Order forms:

  1. Not consulting with a healthcare provider: Sometimes, individuals fill out the form without discussing their medical condition and wishes with a healthcare provider. This professional consultation is crucial for understanding the implications of a DNR order.

  2. Using incorrect personal information: Entering wrong personal details such as a misspelled name or an incorrect date of birth can invalidate the form. It’s essential to double-check this information for accuracy.

  3. Failure to sign the form: A common oversight is not signing the form. For a DNR order to be valid, it must be signed by the person whose name is on the form or by their legally authorized representative if they're unable to sign themselves.

  4. Not having the form witnessed or notarized if required: Depending on the circumstances, Vermont law may require the DNR order to be either witnessed or notarized. Overlooking this step can lead to the document not being legally recognized.

  5. Leaving decision-making sections blank: Some sections of the form may ask for specific medical interventions to be allowed or not allowed. Failing to make these choices clear may result in confusion or unwanted medical procedures.

Documents used along the form

When it comes to managing end-of-life care and medical preferences, the Vermont Do Not Resuscitate (DNR) Order form is a critical document for those who wish to avoid resuscitation in the event their heart or breathing stops. However, this form is often just one piece in a larger puzzle of healthcare directives and planning documents. To ensure one's wishes are fully understood and respected, several other forms and documents might be used alongside the Vermont DNR Order.

  • Advance Directive for Health Care: This comprehensive document allows individuals to specify their preferences for various medical treatments, appoint a healthcare agent, and make decisions about end-of-life care in advance.
  • Medical Power of Attorney: Similar to part of an Advance Directive, this legal document designates someone to make healthcare decisions on behalf of the individual if they are unable to communicate their wishes themselves.
  • Living Will: Often included within an Advance Directive, a Living Will specifically outlines what types of life-sustaining treatments an individual does or does not want to receive in the event of a terminal illness or if they are permanently unconscious.
  • POST (Physician Orders for Life-Sustaining Treatment) Form: This medical order goes beyond a DNR by detailing preferences for other life-sustaining treatments, such as intubation, antibiotics, and artificial nutrition.
  • Health Insurance Portability and Accountability Act (HIPAA) Authorization: This form allows healthcare providers to share your medical information with designated individuals, ensuring your healthcare agent has access to the necessary information to make informed decisions.
  • Hospital Admission Forms: While not a legal document, these forms often include sections where an admitted patient can note their DNR status and other advance care planning documents they have completed.
  • Organ and Tissue Donation Registration: For those interested in organ donation, registering your decision with your state or national registry and including this information in your advance care planning can ensure your wishes are carried out.
  • Emergency Medical Services (EMS) Protocol Form: Some states or medical facilities have specific forms that alert EMS personnel to a patient's DNR status or other critical medical orders to be aware of during an emergency.

Together, these forms create a detailed plan that guides healthcare providers and loved ones through the process of honoring an individual's healthcare and end-of-life preferences. While the Vermont DNR Order specifies one's wishes regarding CPR and resuscitation, the additional documents ensure broader aspects of healthcare and personal agency are covered, making it easier for everyone involved to understand and respect the patient's wishes during critical moments.

Similar forms

The Vermont Do Not Resuscitate (DNR) Order form is akin to an Advance Directive, primarily in its purpose of informing healthcare providers about a patient's preferences regarding medical treatments and interventions at the end of life. Like a DNR, an Advance Directive is legally recognized and communicates the individual's wishes concerning resuscitation efforts, but it differs by being more comprehensive, often including preferences on a wider range of medical treatments, appointing a health care agent, and sometimes detailing end-of-life care preferences such as hospice care or pain management. Both documents are prepared ahead of time, ideally discussed with a healthcare provider, and are designed to respect the patient's autonomy regarding their medical treatment.

Similarly, a Living Will is another document that shares commonalities with the Vermont DNR Order, specifically in expressing medical wishes should the individual become unable to communicate them. A Living Will typically focuses on broader end-of-life decisions beyond resuscitation, such as mechanical ventilation, artificial nutrition, and hydration choices. Though both documents guide healthcare professionals on how to proceed with a patient's care when they cannot speak for themselves, a DNR strictly focuses on the act of not initiating CPR in the event of cardiac or respiratory arrest.

The Medical Orders for Life-Sustaining Treatment (MOLST) or Physician Orders for Life-Sustaining Treatment (POLST) form strongly resembles the Vermont DNR Order in its operational capacity. These forms are medical orders that convey a patient's preferences regarding a range of life-sustaining treatments, including CPR. Both the MOLST/POLST forms and a DNR are designed for patients with serious health conditions and ensure that the healthcare team is aware of and honors the patient's treatment preferences. Unlike the broader scope of an Advance Directive or a Living Will, both the MOLST/POLST and DNR are more immediate, actionable orders used by medical professionals.

Last but certainly not least, a Health Care Proxy is a legal document that, while distinct, is related to the intent behind a DNR order. This document allows an individual to designate another person, a proxy or agent, to make healthcare decisions on their behalf if they are unable to do so themselves. While the Health Care Proxy focuses on the appointment of an agent rather than detailing specific medical treatments, it supports the same ethos as a DNR by ensuring the patient's medical care aligns with their values and preferences when they cannot communicate. In combination with a DNR, it ensures decisions about CPR and other treatments respect the patient's wishes.

Dos and Don'ts

Filling out the Vermont Do Not Resuscitate (DNR) Order form is a crucial step for those who wish to make their health care wishes known in advance, particularly concerning resuscitation efforts during a medical emergency. To ensure the process is carried out smoothly and effectively, here are essential dos and don'ts to keep in mind:

  • Do carefully read through the form before beginning to fill it out. Understanding each section will help in providing accurate and clear information.
  • Do discuss your wishes with your health care provider before completing the form. This discussion can provide valuable guidance and ensure your decisions are well-informed.
  • Do use black ink when filling out the form to ensure that it is legible and photocopies clearly.
  • Do provide complete information, including your full legal name, date of birth, and other personal details as requested to ensure the form is easily identifiable as yours.
  • Do ensure that the form is signed and dated by the required parties, including yourself, a witness, and your healthcare provider, to validate the DNR order.
  • Do make copies of the completed form and keep the original in a place where it is easily accessible to emergency personnel.
  • Do inform family members, close friends, and caregivers of your DNR order, where it is located, and discuss your wishes with them.
  • Do not fill out the form in a hurry. Take your time to consider your choices carefully and to ensure that all information provided is accurate and reflective of your wishes.
  • Do not leave any sections blank unless instructed to do so. If a section does not apply, write “N/A” (for Not Applicable) to indicate this.
  • Do not forget to review and update your DNR order periodically, especially if your health status or wishes change. A new form must be completed for updates to take effect.

By following these guidelines, individuals can ensure that their healthcare preferences, particularly concerning resuscitation efforts, are clearly articulated and respected. Remember, the DNR form is a legal document, and its completion should be taken seriously and done with careful consideration and understanding.

Misconceptions

In addressing the Vermont Do Not Resuscitate (DNR) Order form, there are several misconceptions that can lead to confusion and misinformed decisions. By clarifying these misunderstandings, individuals can make better-informed choices regarding their health care preferences.

  • Only the elderly or terminally ill can request a DNR order. It's a common misconception that DNR orders are exclusive to older adults or those with terminal conditions. In reality, any individual, regardless of age or health status, can request a DNR order in Vermont if they have strong personal beliefs or reasons for not wanting resuscitative measures taken.
  • A DNR order means no medical treatment will be provided. This misunderstanding can cause unnecessary worry. A DNR order specifically refers to the withholding of cardiopulmonary resuscitation (CPR) in the event that an individual's breathing or heartbeat stops. It does not mean that other forms of medical care, such as pain management or antibiotics, will be denied.
  • Doctors can unilaterally decide to implement a DNR order for a patient. In Vermont, a DNR order can only be put into place if the patient (or their legally appointed health care agent) consents to it. Health care providers must follow the wishes of the patient or their designated representative when it comes to decisions about resuscitation.
  • A DNR order is permanent and cannot be revoked. Some people hesitate to request a DNR order because they fear it cannot be changed. However, a DNR order can be revoked at any time by the patient or their designated health care agent. It's important for individuals to regularly review and discuss their wishes with their healthcare providers and loved ones.
  • If you have a DNR order, you cannot be admitted to a hospital. This final misconception could deter someone from opting for a DNR order due to a misunderstanding of its implications. Having a DNR order does not prevent someone from being admitted to the hospital for treatment of illnesses or injuries. The DNR specifically applies to the event of cardiac or respiratory arrest and does not restrict access to other medical treatments or hospital care.

By debunking these misconceptions, it's hoped that individuals feel more empowered and knowledgeable when considering their options regarding a DNR order in Vermont. It's always advisable to consult with healthcare providers and legal advisors to ensure that one's wishes are clearly understood and properly documented.

Key takeaways

Completing and using the Vermont Do Not Resuscitate (DNR) Order form requires careful attention to specific details and procedures. The following key takeaways are essential for individuals and healthcare professionals to understand:

  • The Vermont DNR Order form must be completed accurately to ensure that a person’s wishes regarding resuscitation are respected in an emergency.
  • Only licensed healthcare providers have the authority to sign and activate the DNR Order, verifying the individual's informed decision.
  • Communication is crucial; individuals should discuss their wishes with family, healthcare agents, and primary care providers before completing the form.
  • The form needs to be accessible; it should be kept in an easily accessible place so that emergency responders can find and follow it during an emergency.
  • Photocopies of the signed DNR Order are considered as valid as the original document.
  • Wearing a DNR bracelet or necklace can also serve as an immediate indicator of the individual’s DNR status to emergency personnel.
  • A DNR Order can be revoked at any time by the individual, provided they are capable of making their own medical decisions.
  • It’s important to review and potentially update the DNR Order periodically, especially after any major health changes or treatments.
  • The form is specific to Vermont and may not be recognized if the individual receives medical care outside of the state.
  • Completing a DNR Order does not affect the quality of care provided to the individual; it only guides emergency medical personnel in the event of cardiac or respiratory arrest.

Understanding these key points ensures that the individual’s wishes are clearly communicated and respected, which is critical in emergency situations. It’s recommended to seek guidance from healthcare professionals when considering a DNR Order..

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