Physician Order For Life Sustaining Treatment Utah Life With Dignity Order Page 2
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1
2Section D
Artificially administered fluid and nutrition:
(Comfort measures are always provided)
Check all
Feeding Tube:
IV Fluids:
that apply
___ No feeding tube
___ No IV fluids
___ Defined trial period of feeding tube
___ Defined trial period of IV fluids
___ Long-term feeding tube
___ IV Fluids
Other Instructions or Clarification:____________________________________________________
_______________________________________________________________________________
Section E
Discussed with:
Check all
___ Patient / Parent(s) of Minor Child
that apply
___ Surrogate (source of legal authority, name, and phone number):
_______________________________________________________________________________
___ Other (name and phone number): ________________________________________________
Patient preferences to guide physician in ordering life-sustaining treatment
Section F
I have given significant thought to life-sustaining treatment. Please see the following for more
information about my preferences:
Advance Directive
___ no ___ yes
Other: ________________________________________________________________________
I have expressed my preferences to my physician or health care provider(s) and agree with the
treatment order on this document. Please review these orders if there is a substantial permanent
change in my health status, such as:
Close to death
Advance progressive illness
Improved condition
Permanently unconscious
Extraordinary suffering
Surgical procedures
Brief summary of medical condition and brief explanation of treatment choice:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Signature of person preparing form (if
Print name and phone number
Date prepared:
not patient’s physician)
Signature of physician or other licensed
Print name and license number
Date signed:
practitioner
Signature of second physician or other
Print name and license number
Date signed:
licensed practitioner (required for minor
patients only)
Patient, Parent, or Surrogate signature
Print name and phone number
Date signed:
Patient, Parent, or Surrogate signature
Print name and phone number
Date signed:
Review and Change to Life with Dignity Order
Review this form whenever any of the following happen:
1.
The patient is transferred from one care setting to another;
2.
The patient’s health status changes substantially and permanently; or
3.
The patient’s treatment preferences change.
If the patient or the patient’s surrogate changes the treatment preferences in this order, complete a new form and place
it in the patient’s medical record. This form is valid for both adult and pediatric patients
A COPY OF THIS FORM MUST ACCOMPANY THE PATIENT WHEN TRANSFERRED OR DISCHARGED
(INCLUDING TRANSFERS TO HOSPITAL EMERGENCY DEPARTMENTS)
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