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2 UNIFORM DNR ADVANCE DIRECTIVE UNIFORM DNR ADVANCE DIRECTIVE UNIFORM DNR ADVANCE DIRECTIVE
Illinois Department of Public Health
UNIFORM DO-NOT-RESUSCITATE (DNR) ADVANCE DIRECTIVE
PHYSICIAN ORDERS FOR LIFE-SUSTAINING TREATMENT (POLST)
HIPAA (HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT of 1996) PERMITS DISCLOSURE
TO HEALTH CARE PROFESSIONALS AS NECESSARY FOR TREATMENT
Patient Last Name
Patient First Name
MI
Follow these orders until changed. These medical
orders are based on the patient’s medical condition
and preferences. Any section not completed does
not invalidate the form and implies initiating all
Date of Birth (mm/dd/yy)
Gender
treatment for that section. With significant change
q M
q F
of condition, new orders may need to be written.
Address (street/city/state/ZIPcode)
See also Guidance for Health Care Professionals at
A
CARDIOPULMONARY RESUSCITATION (CPR) Patient has no pulse and is not breathing.
q Attempt Resuscitation/CPR
(Selecting CPR means Intubation and Mechanical Ventilation in Section B is selected)
Check
q Do Not Attempt Resuscitation/DNR
One
When not in cardiopulmonary arrest, follow orders B and C.
B
MEDICAL INTERVENTIONS Patient has pulse and/or is breathing.
q Comfort Measures Only (Allow Natural Death). Relieve pain and suffering through the use of medication by
Check
appropriate route, positioning, wound care and other measures. Use oxygen, suction and manual treatment of
One
airway obstruction as needed for comfort. Patient prefers no transfer to hospital for life-sustaining treatments.
Transfer if comfort needs cannot be met in current location. Treatment Plan: Maximize comfort through
symptom management.
q Limited Additional Interventions In addition to care described in Comfort Measures Only, use medical treatment,
antibiotics, IV fluids and cardiac monitor as indicated. No intubation or mechanical ventilation. May consider less invasive
airway support (e.g., CPAP, BiPAP). Transfer to hospital if indicated. Generally avoid the intensive care unit.
Treatment Plan: Provide basic medical treatments.
q Intubation and Mechanical Ventilation In addition to care described in Comfort Measures Only and Limited Additional
Interventions, use intubation and mechanical ventilation as indicated. Transfer to hospital and/or intensive care unit
if indicated. Treatment Plan: Life support measures, including intubation, in the intensive care unit.
q Additional Orders _____________________________________________________________________________
C
ARTIFICIALLY ADMINISTERED NUTRITION Offer food by mouth, if feasible and as desired.
q
No artificial nutrition by tube.
Additional Instructions (e.g., length of trial period)
Check
q Defined trial period of artificial nutrition by tube.
_____________________________________________
One
(optional)
q Long-term artificial nutrition by tube.
_____________________________________________
D
DOCUMENTATION OF DISCUSSION (Check all appropriate boxes below)
q Patient
q Agent under health care power of attorney
q Parent of minor
q Health care surrogate decision maker (See Page 2 for priority list)
Signature of Patient or Legal Representative
Signature (required)
Name (print)
Date
_______________________________________________
_________________________________
____________
Signature of Witness to Consent (Witness required for a valid form)
I am 18 years of age or older and acknowledge the above person has had an opportunity to read this form and have witnessed the
giving of consent by the above person or the above person has acknowledged his/her signature or mark on this form in my presence.
Signature (required)
Name (print)
Date
_______________________________________________
_________________________________
____________
E
SIGNATURE OF ATTENDING PHYSICIAN
My signature below indicates to the best of my knowledge and belief that these orders are consistent with the patient’s medical condition and preferences.
Print Attending Physician Name (required)
Phone
______________________________________________________________
(
) _________ - ______________
Attending Physician Signature (required)
Date (required)
Page 1
______________________________________________________________
_______________________
SEND A COPY OF FORM WITH PATIENT WHENEVER TRANSFERRED OR DISCHARGED
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