Illinois Do Not Resuscitate Form Details

The Illinois DNR form is a document that residents of Illinois can use to request information about Department of Natural Resources (DNR) programs and services. The form can be used to request information about hunting, fishing, and other outdoor recreation opportunities in the state. Additionally, the form can be used to request information about environmental protection and conservation initiatives in Illinois. Residents who are interested in learning more about the DNR can use the Illinois DNR form to get started.

You'll find information about the type of form you want to complete in the table. It will show you the length of time you'll need to complete illinois dnr form, exactly what parts you need to fill in, etc.

QuestionAnswer
Form NameIllinois Dnr Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesillinois dnr form, illinois do not resuscitate, do not resuscitate form, illinois do dnr

Form Preview Example

HIPAA PERMITS DISCLOSURE OF DNR/POLST TO HEALTH CARE PROFESSIONALS AS NECESSARY FOR TREATMENT

IDPH DNR/POLST IDPH DNR/POLST IDPH DNR/POLST IDPH DNR/POLST IDPH DNR/POLST IDPH DNR/POLST

 

STATE OF ILLINOIS

DO-NOT-RESUSCITATE (DNR)/PRACTITIONER ORDERS

 

Illinois Department of Public Health

 

FOR LIFE-SUSTAINING TREATMENT (POLST) FORM

For patients, use of this form is completely voluntary.

Patient Last Name

Patient First Name

MI

Follow these orders until changed. These medical orders

 

 

 

are based on the patient’s medical condition and prefer-

Date of Birth (mm/dd/yy)

Gender q M

q F

ences.Anysectionnotcompleteddoesnotinvalidatethe

 

 

 

form and implies initiating all treatment for that section.

 

 

 

With significant change of condition new orders may

Address (street/city/state/ZIPcode)

 

need to be written.

 

 

 

 

A

CARDIOPULMONARY RESUSCITATION (CPR) If patient has no pulse and is not breathing.

 

Check

q Attempt Resuscitation/CPR

 

 

q Do Not Attempt Resuscitation/DNR

(Selecting CPR means Full Treatment in Section B is selected)

 

 

One

 

 

 

When not in cardiopulmonary arrest, follow orders B and C.

 

B

MEDICAL INTERVENTIONS If patient is found with a pulse and/or is breathing.

 

CheckOne

q Full Treatment: Primary goal of sustaining life by medically indicated means. In addition to treatment

described in Selective Treatment and Comfort-Focused Treatment, use intubation, mechanical ventilation and

(optional) cardioversion as indicated. Transferto hospital and/or intensive care unit if indicated.

 

qSelective Treatment: Primary goal of treating medical conditions with selected medical measures. In addition to treatment described in Comfort-Focused Treatment, use medical treatment, IV fluids and IV medications (may include antibiotics and vasopressors), as medically appropriate and consistent with patient preference. Do Not Intubate. May consider less invasive airway support (e.g. CPAP, BiPAP). Transfer to hospital, if indicated. Generally avoid the intensive care unit.

qComfort-Focused Treatment: Primary goal of maximizing comfort. Relieve pain and suffering through the use of medication by any route as needed; use oxygen, suctioning and manual treatment of airway obstruction. Do not use treatments listed in Full and Selective Treatment unless consistent with comfort goal.

Request transfer to hospital only if comfort needs cannot be met in current location.

Optional Additional Orders________________________________________________________________________

CMEDICALLYADMINISTERED NUTRITION (if medically indicated) Offer food by mouth, if feasible and as desired. q Long-term medically administered nutrition, including feeding tubes. Additional Instructions (e.g., length of trial period)

Check

q Trial period of medically administered nutrition, including feeding tubes.

__________________________________________

One

(optional)

q No medically administered means of nutrition, including feeding tubes.

__________________________________________

 

 

 

 

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

 

_______________________________________________

_________________________________

____________

 

 

 

 

 

 

SignatureofWitnesstoConsent (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

 

_______________________________________________

_________________________________

____________

 

 

 

 

 

 

ESignatureofAttendingPractitioner(physician,licensedresident(secondyearorhigher),advancedpracticenurseorphysicianassistant) Mysignaturebelowindicatestothebestofmyknowledgeandbeliefthattheseordersareconsistentwiththepatient’smedicalconditionandpreferences.

 

PrintAttending Practitioner Name (required)

Phone

 

 

__________________________________________________

(

) _________ - ______________

 

 

 

 

 

Attending Practitioner Signature (required)

Date (required)

 

 

 

 

 

Page 1

__________________________________________________

_______________________

 

 

 

 

 

 

Form Revision Date January 2015

 

(Prior form versions are also valid.)

SENDACOPYOF FORM WITH PATIENT WHENEVER TRANSFERRED OR DISCHARGED • COPYONANYCOLOR OF PAPER ISACCEPTABLE • 2015

IDPH DNR/POLST IDPH DNR/POLST IDPH DNR/POLST IDPH DNR/POLST IDPH DNR/POLST IDPH DNR/POLST

HIPAA PERMITS DISCLOSURE OF DNR/POLST TO HEALTH CARE PROFESSIONALS AS NECESSARY FOR TREATMENT

DNR/POLST

 

 

 

 

 

**THIS SIDE FOR INFORMATIONAL PURPOSES ONLY**

 

 

 

TheIllinoisDepartmentofPublicHealth(IDPH)DoNot

Resuscitate(DNR)/PractitionerOrdersforLifeSustaining

Treatment

 

 

 

Patient Last Name

 

Patient First Name

MI

 

IDPH

 

(POLST)isalwaysvoluntary.Thisorderrecordsyourwishesformedicaltreatmentinyourcurrentstateofhealth.Once

 

 

initial medical treatment is begun and the risks and benefits of further therapy are clear, your treatment wishes may

 

 

 

change. Your medical care and this form can be changed to reflect your new wishes at any time. However, no form can

 

 

address all the medical treatment decisions that may need to be made. The Power ofAttorney for Health CareAdvance

 

 

 

Directive form (POAHC) is recommended for all capable adults, regardless of their health status.APOAHC allows you

 

DNR/POLST

 

to document, in detail, your future health care instructions and name a Legal Representative to speak for you if you are

 

 

unable to speak for yourself.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Advance Directive Information

 

 

 

 

 

 

 

 

I also have the following advance directives (OPTIONAL)

 

 

IDPH

 

q Health Care Power ofAttorney

q Living Will Declaration

q Mental Health Treatment Preference Declaration

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Contact Person Name

 

 

 

Contact Phone Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Health Care Professional Information

 

 

DNR/POLSTIDPH

 

Preparer Name

 

 

 

Phone Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Preparer Title

 

 

 

Date Prepared

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Completing the IDPH Do Not Resuscitate (DNR)/POLST Form

 

 

 

The completion of a DNR/POLST form is always voluntary, cannot be mandated and may be changed at any time.

 

• ADNR/POLST should reflect current preferences of persons completing the DNR/POLST Form; encourage completion of a POAHC.

 

 

DNR/POLST

 

• Verbal/phone orders are acceptable with follow-up signature by attending physician in accordance with facility/community policy.

 

• Use of original form is encouraged. Photocopies and faxes on any color of paper also are legal and valid forms.

 

 

 

 

 

 

 

 

Reviewing a Do Not Resuscitate (DNR)/POLST Form

 

 

 

 

 

 

This DNR/POLST form should be reviewed periodically and if:

 

 

 

 

IDPH

 

• The patient is transferred from one care setting or care level to another,

 

 

 

• or there is a substantial change in the patient’s health status,

 

 

 

 

 

• or the patient’s treatment preferences change,

 

 

 

 

 

 

• or the patient’s primary care professional changes.

 

 

 

 

 

Voiding or revoking a Do Not Resuscitate (DNR)/POLST Form

 

 

 

 

 

 

DNR/POLST

 

• Apatient with capacity can void or revoke the form, and/or request alternative treatment.

 

 

 

• Changing, modifying or revising a DNR/POLST form requires completion of a new DNR/POLST form.

 

 

 

 

 

 

 

 

• Draw line through sectionsAthrough E and write “VOID” across page if any DNR/POLST form is replaced or becomes invalid.

 

 

 

Beneath the written "VOID" write in the date of change and re-sign.

 

 

 

 

 

 

• If included in an electronic medical record, follow all voiding procedures of facility.

 

 

IDPH

 

Illinois Health Care Surrogate Act (755 ILCS 40/25) Priority Order

 

 

 

1.Patient’s guardian of person

 

 

5.Adult sibling

 

 

 

 

2.Patient’s spouse or partner of a registered civil union

6.Adult grandchild

 

 

 

3.Adult child

 

 

7.Aclose friend of the patient

 

 

 

4.Parent

 

 

8.The patient’s guardian of the estate

 

 

DNR/POLST

 

 

 

 

 

 

 

 

 

 

For more information, visit the IDPH Statement of Illinois law at

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

http://www.idph.state.il.us/public/books/advin.htm

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HIPAA (HEALTH INSURANCE PORTABILITYAND ACCOUNTABILITYACT of 1996) PERMITS DISCLOSURE

 

 

IDPH

 

TO HEALTH CARE PROFESSIONALS AS NECESSARY FOR TREATMENT

 

 

 

 

 

 

IOCI 15-464

 

 

 

 

Page 2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IDPH DNR/POLST IDPH DNR/POLST IDPH DNR/POLST IDPH DNR/POLST IDPH DNR/POLST IDPH DNR/POLST

SENDACOPYOF FORM WITH PATIENT WHENEVER TRANSFERRED OR DISCHARGED • COPYONANYCOLOR OF PAPER ISACCEPTABLE • 2015

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