Dnr/colst Clinician Orders For Dnr/cpr And Other Life Sustaining Treatment Page 3
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4HIPAA PERMITS DISCLOSURE OF COLST TO OTHER HEALTH CARE PROFESSIONALS AS NECESSARY
ORDERS FOR OTHER LIFE-SUSTAINING TREATMENT
(If patient/resident is breathing and/or has pulse)
B
INTUBATION AND MECHANICAL VENTILATION INSTRUCTIONS:
If patient has DNR order and has progressive or impending pulmonary failure without acute cardiopulmonary arrest:
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Do Not Intubate/Multi-Lumen Airway (DNI)
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Trial Period of Intubation/Multi-Lumen Airway and ventilation
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Intubation/Multi-Lumen Airway and long-term mechanical ventilation if needed
C
TRANSFER TO HOSPITAL
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Do not transfer unless comfort care needs cannot be met in current location or if severe symptoms cannot be
otherwise controlled
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Transfer
ANTIBIOTICS
D
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No antibiotics. Use other measures to relieve symptoms
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Determine use or limitation of antibiotics when infection occurs, with comfort as goal
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Use antibiotics
E
ARTIFICIALLY ADMINISTERED NUTRITION:
Offer food and liquids by mouth if feasible.
Feeding tube
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No feeding tube
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Trial period of feeding tube (Goal:_____________________________________)
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Long-term feeding tube
Parenteral nutrition or hydration (e.g. IV fluids or Total Parenteral Nutrition)
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No parenteral nutrition or hydration
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Trial period of parenteral nutrition or hydration (Goal:____________________________________)
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Long term parenteral nutrition or hydration
F
:
MEDICAL INTERVENTIONS
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COMFORT MEASURES ONLY Use medication by any route, positioning, wound care and other measures to
to relieve pain and suffering. Use oxygen, oral suction and manual treatment of airway obstruction as needed for
comfort. Offer food and fluids by mouth, if feasible.
□
LIMITED ADDITIONAL INTERVENTIONS Includes care described above. Use medical treatments and
IV fluids as indicated. Avoid intensive care if possible.
□
FULL TREATMENT Includes care described above. Use defibrillation and intensive care as indicated.
G
Other Instructions
_______________________________________________________________________________________
______________________________________________________________________________________
_____________________________________________________________________________________
GIVE COPY TO PATIENT AND REPRESENTATIVE
SEND FORM WITH PATIENT WHENEVER TRANSFERRED OR DISCHARGED
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