Physician Order For Life Sustaining Treatment Template
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1
2Utah Department of Health
Bureau of Health Facility Licensing, Certification and Resident Assessment
Physician Order for Life Sustaining Treatment
Utah Life with Dignity Order
Version 2 – 9/09
State of Utah Rule R432-31
( )
This is a physician order sheet based on patient wishes
Last Name of Patient:
and medical indications for life-sustaining treatment. Place
this order in a prominently visible part of the patient’s
record. Both the patient and the physician must sign this
First Name/Middle Initial:
order (two physicians must sign if the patient is a minor
child). When the patient’s condition makes this order
applicable, first follow this order, and then, if necessary,
Date of Birth:
contact the signing physician.
Physician’s Name:
Effective Date of this Order:
Physician’s Phone:
(IF NOTHING IN A SECTION IS CHECKED, CAREGIVERS SHOULD PROVIDE THE FULLEST TREATMENT DESCRIBED IN THAT
SECTION UNLESS THAT TREATMENT DIRECTLY CONFLICTS WITH A TREATMENT CHECKED IN ANOTHER SECTION)
Section A
Treatment options when the patient has no pulse and is not breathing:
Check one
___ Attempt to resuscitate
____ Do not attempt or continue any resuscitation (DNR)
Other instructions or clarification:____________________________________________________
_________________________________________________________________
_________________________________________________________________
Section B
Treatment options when the patient has a pulse and is breathing:
Check one
___ Comfort measures only: Oral and body hygiene; reasonable efforts to offer food and fluids
orally; medication, oxygen, positioning, warmth, and other measures to relieve pain and suffering.
Provide privacy and respect for the dignity and humanity of the patient. Transfer to hospital only if
comfort measures can no longer be effectively managed at current setting.
___ Limited additional interventions: Includes care above. May also include suction, treatment of
airway obstruction, bag/valve/mask ventilation, monitoring of cardiac rhythm, medications, IV fluids.
Transfer to hospital if indicated, but no endotracheal intubation or long-term life support
measures.
Other instructions or clarification:_________________________________________________
_________________________________________________________________
___ Full treatment: Includes all care above plus endotracheal intubation, defibrillation/cardioversion,
and any other life sustaining care required.
If necessary, transfer to (hospital name): _____________________________________________
Other Instructions or clarification:____________________________________________________
_________________________________________________________________
_________________________________________________________________
Section C
Antibiotics:
(Comfort measures are always provided)
Check all
___ No antibiotics
that apply
___ Antibiotics may be administered
Other Instructions or clarification:________________________________________________
______________________________________________________________
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