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Uniform Do-Not-Resuscitate (DNR) Advance Directive - Illinois
| Uniform Do-Not-Resuscitate (DNR) Advance Directive Form. This is a Illinois form and can be used in Miscellaneous Statewide . |
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UNIFORM DNR ADVANCE DIRECTIVE UNIFORM DNR ADVANCE DIRECTIVE UNIFORM DNR ADVANCE DIRECTIVE UNIFORM DNR ADVANCE DIRECTIVE UNIFORM DNR ADVANCE DIRECTIVE UNIFORM DNR ADVANCE DIRECTIVE UNIFORM DNR ADVANCE DIRECTIVE UNIFORM DNR ADVANCE DIRECTIVE 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 Follow these orders until changed. These medical Patient Last Name Patient First Name orders are based on the patient's medical condition and preferences. Any section not completed does not invalidate the form and implies initiating all treatment for that section. With significant change of condition, new orders may need to be written. See also Guidance for Health Care Professionals at http://www.idph.state.il.us/public/books/advin.htm. MI Date of Birth (mm/dd/yy) Address (street/city/state/ZIPcode) Gender qM qF Check One A B 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) q Do Not Attempt Resuscitation/DNR When not in cardiopulmonary arrest, follow orders B and C. 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 appropriate route, positioning, wound care and other measures. Use oxygen, suction and manual treatment of 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 _____________________________________________________________________________ Check One q No artificial nutrition by tube. Check q Defined trial period of artificial nutrition by tube. One (optional) q Long-term artificial nutrition by tube. C ARTIFICIALLY ADMINISTERED NUTRITION Offer food by mouth, if feasible and as desired. Additional Instructions (e.g., length of trial period) _____________________________________________ _____________________________________________ D DOCUMENTATION OF DISCUSSION (Check all appropriate boxes below) q Patient q Parent of minor Signature (required) _______________________________________________ q Agent under health care power of attorney q Health care surrogate decision maker (See Page 2 for priority list) Name (print) _________________________________ Date ____________ Signature of Patient or Legal Representative 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) ______________________________________________________________ Attending Physician Signature (required) ______________________________________________________________ Phone ( ) _________ - ______________ Page 1 Date (required) _______________________ SEND A COPY OF FORM WITH PATIENT WHENEVER TRANSFERRED OR DISCHARGED American LegalNet, Inc. www.FormsWorkFlow.com UNIFORM DNR ADVANCE DIRECTIVE UNIFORM DNR ADVANCE DIRECTIVE UNIFORM DNR ADVANCE DIRECTIVE UNIFORM DNR ADVANCE DIRECTIVE UNIFORM DNR ADVANCE DIRECTIVE UNIFORM DNR ADVANCE DIRECTIVE UNIFORM DNR ADVANCE DIRECTIVE UNIFORM DNR ADVANCE DIRECTIVE UNIFORM DNR ADVANCE DIRECTIVE UNIFORM DNR ADVANCE DIRECTIVE UNIFORM DNR ADVANCE DIRECTIVE **THIS SIDE FOR INFORMATIONAL PURPOSES ONLY** Patient Last Name Patient First Name MI The Illinois Department of Public Health (IDPH) Uniform Do Not Resuscitate (DNR) Advance Directive is always voluntary and is for persons with advanced or serious illness or frailty. This order records your wishes for medical treatment in your current state of health. 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 of Attorney for Health Care Advance Directive form (POAHC) is recommended for all capable adults, regardless of their health status. A POAHC allows you 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) q Health Care Power of Attorney Contact Person Name q Living Will Declaration q Mental Health Treatment Preference Declaration Contact Phone Number Health Care Professional Information Preparer Name Phone Number Preparer Title Date Prepared Completing the IDPH Uniform Do Not Resuscitate (DNR) Advance Directive Form · · · · The completion of a DNR form is always voluntary, cannot be mandated and may be changed at any time. A DNR form should reflect current preferences of pers
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