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Vermont DNR/COLST Orders

One essential element of providing quality end-of-life care involves honoring patient preferences.

In the past a Do-Not-Resuscitate Order (DNR) has been used when a patient does not wish to have Cardiopulmonary Resuscitation (CPR). In recent years the 'old DNR' order has been incorporated into a new form known as the DNR/COLST order by the Vermont Department of Health.

This more complete document is a clinician order for life-sustaining treatment (COLST) and conveys patients' wishes for CPR, intubation, transfer to the hospital, antibiotics, artificial nutrition and hydration, as well as overall treatment goals.

Please note the mandated use of the Vermont Department of Health's DNR/COLST Form in the following circumstances:

Please utilize the FAQs below for further explanations, definitions and clarifications. If you have additional questions please let us know and we will gladly answer them and update our website.



DNR/COLST Frequently Asked Questions (FAQ)

General Information & Definitions:

Clinician Order for Life Sustaining Treatment. In Vermont the form is referred to as DNR/COLST (Do Not Resuscitate Order/Clinician Order for Life Sustaining Treatment).

  1. Must be signed by the patient's clinician
  2. Include name of the patient, agent, guardian or other individual giving informed consent and their relationship to the patient.
The old 'DNR' order:
  • Only dealt with CPR
  • Does not meet the current legal requirements for a DNR order
The DNR/COLST order:
  • Deals with CPR as well as:
    • Intubation
    • Transfer to hospital
    • Antibiotics
    • Supplemental nutrition and hydration
    • Overall goals of care
  • Meets all legal requirements
  • Helps patients avoid treatments (not only CPR) that they do not want
  • An Advance Directive is completed by the patient, allows for nuances and is not honored in an out of hospital emergency.
  • The DNR/COLST order is completed by a clinician, is black and white and is honored in an out of hospital emergency.
  • Medical futility refers to interventions that are unlikely to produce any significant benefit for the patient.
  • An order based on futility must include a certification by the clinician and a second clinician that resuscitation would not prevent imminent death of the patient, should the patient experience cardiopulmonary arrest.

It is recommended to review goals of care and treatment wishes with patients at least annually or if there is a change in patient's current condition/status.

Yes, if the document complies with the statutory requirements in effect at the time the document was executed.

Completing a DNR/COLST:

- Medical Doctor
- Osteopathic Physician
- Advanced Practice Registered Nurse
- Physician Assistant

*All of the above are referred to as 'clinician' for the remainder of the document

No, a DNR/COLST is intended for patients with serious health conditions who:

  • Want to express preferences for life-sustaining treatment; and/or
  • eside in a long-term care facility or require long-term care services; and/or
  • Have a terminal illness
  • Must be signed by the patient's clinician
  • Include name of the patient, agent, guardian or other individual giving informed consent and their relationship to the patient
  • Written on basis of informed consent or futility.
  • An order based on informed consent must include the name of the individual giving informed consent.
  • An order based on futility must include a certification by the clinician and a second clinician that resuscitation would not prevent imminent death of the patient, should the patient experience cardiopulmonary arrest.
  • If the patient is in a health care facility, the clinician must certify that the facility's DNR policy has been followed.
  • The clinician may authorize the issuance of DNR/COLST identification to the patient (such as a bracelet).
  • Clinician must certify that clinician has consulted or made an attempt to consult with the patient, and the patient's agent or guardian.
  • An out-of-hospital DNR/COLST shall be issued on the Department of Health's Vermont DNR/COLST form.
  • Health care facilities and Residential care facilities may document DNR/COLST orders in the patient's medical record in a facility specific manner when the patient is in their care. The criteria for these forms are described below.

DNR Orders must:

  • Be signed by the patient's clinician
  • Certify that the clinician has consulted, or made an effort to consult, with the patient, and the patient's agent or guardian, if there is an appointed agent or guardian
  • Must include: the name of the patient, agent or guardian giving informed consents OR meet the futility standard

COLST Orders must:

  • Be signed by the patient's clinician
  • Include the name of the patient, agent or guardian giving informed consent

Facility and Provider Responsibilities once a DNR/COLST has been completed:

Every health care facility and residential care facility shall:

  • Ensure that a patient's advance directive and DNR/COLST order are promptly available when services are to be provided.
  • Ensure that a DNR/COLST order is prominently noted on any file jacket or folder and that a note is entered into any electronic medical record.
  • Place a copy of the completed DNR/COLST in the patient's medical record
  • Issue a DNR identification (bracelet, necklace, anklet) to the patient
  • Provide instructions to the patient as to the appropriate means of displaying DNR/COLST order. For example, having a copy on the refrigerator of your home.

Yes, it is now mandated that Advance Directive and DNR/COLST orders be prominently noted on any file jacket or folder and that a note is entered into any electronic database of the provider or the facility.

No, the VADR is a database that allows people to electronically store a copy of their Advance Directive in a secure database. That database may be accessed when needed by authorized health care providers, health care facilities, residential care facilities, funeral directors and crematory operators. For more information: http://healthvermont.gov/vadr

Providers and Facilities are required to check the registry at the time that any individual without capacity is admitted or provided services to determine whether that individual has an advance directive.

Responsibilities upon patient transfer or discharge:

Yes, all out-of-hospital DNR/COLST orders are mandated to be on the Department of Health's Vermont DNR/COLST form.

There is a facility specific exemption for patients residing in a health care facility or residential care facility.

A copy of any Advance Directive, DNR, and/or COLST order shall be transmitted with the patient or principal.

Any DNR/COLST orders to be continued upon discharge, during transport, or in another setting shall be documented on the Vermont DNR/COLST form.

Reviewing or Updating DNR/COLST orders:

The minimum recommended time frame to review and update DNR/COLST is annually. It is recommended that DNR/COLST be reviewed periodically and a new order completed if necessary when:

  • The patient is transferred from one care setting to another
  • The patient is transferred to a new care level
  • There is substantial change in the patient's health status
  • The patient's treatment goals and preferences change

Out of State DNR/Orders for Life Sustaining Treatment:

Yes, a health care provider shall honor in good faith an out of state DNR order, orders for life sustaining treatment or out of state DNR identification if there is no reason to believe that what is presented is invalid.

Other Information:

A DNR/COLST order informed consent study committee has been created and is studying the criteria used for individuals giving informed consent who are not the patient, the patient's agent or the patient's guardian. The Vermont Department of Health is overseeing this study committee and will be making recommendations to the legislature by December 1, 2011.


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