Vermont Do Not Resuscitate Order Form

Information you will need

• What are the patient’s CPR orders?
• What’s the basis for the DNR order?
• What's the name of the other cilinician?
• What are the medical intervention guidelines?
• Is the patient in a health care facility or a residential care facility?
• What’s the patient’s full name?
• What's the patient's birthdate?
• What are the artificially administered hydration orders?
• What's the clinician's full name?
• What's the name of the hospice agency?
• What's the phone number and contact of the hospice agency?
• What’s the review date?
• What’s the name of the clinician who reviewed this form?
• Where was this DNR/COLST reviewed?
• What's the outcome of the review?
• Is consent being given verbally?
• What are the intubation and ventilation instructions?
• What are the artificially administered nutrition orders?
• What are the antibiotics administration orders?
• What's the name of the health care agent and their phone number? (if applicable)
• What's the name of the guardian and their phone number? (if applicable)
• What's the name of the surrogate and their phone number? (if applicable)
• What's the name of the facility? (if applicable)
• What are the patient’s preferences and treatment goals?

…and 7 more fields in the PDF.

Completed by the agent.

The form includes 5 signature lines.