Illinois Dnr Form – Fill Out and Use This PDF

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.

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

_______________________________________________

_________________________________

____________

PrintAttending Practitioner Name (required)

Phone

__________________________________________________

(

) _________ - ______________

Attending Practitioner Signature (required)

Date (required)

Page 1

__________________________________________________

_______________________

Form Revision Date January 2015

(Prior form versions are also valid.)

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