Homepage Official Utah Do Not Resuscitate Order Form
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In Utah, individuals have the option to express their wishes regarding the extent of medical care they wish to receive in the event of a life-threatening emergency through the Utah Do Not Resuscitate (DNR) Order form. This legal document is crucial for those who prefer not to undergo certain life-sustaining treatments, like cardiopulmonary resuscitation (CPR), if they stop breathing or their heart stops beating. It is designed to respect the patient's wishes and to guide healthcare providers in accordance with those wishes. Understanding the specifics of the form, including who it is for, how one can request it, and the implications of filling it out, is essential for anyone considering this option. The form itself is a product of thoughtful legislation, aimed at ensuring that individual preferences regarding emergency medical care are honored, providing both patients and their families peace of mind during difficult times. Additionally, the form's legal status mandates that healthcare professionals adhere to the stipulated wishes, thereby underscoring the importance of clear communication and precise documentation in the healthcare decision-making process.

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Utah Do Not Resuscitate Order Template

This document serves as a Do Not Resuscitate Order (DNR) under the guidelines of Utah State Law. It reflects the wishes of the individual named below, stating that no attempts should be made to revive them through cardiopulmonary resuscitation (CPR) in case of cardiac or respiratory arrest.

Please fill in the required information to ensure this document reflects your wishes accurately.

Patient Information:

  • Full Name: _______________
  • Date of Birth: _______________
  • Address: _______________
  • City: _______________
  • State: Utah
  • Zip Code: _______________

Emergency Contact Information:

  • Full Name: _______________
  • Relationship: _______________
  • Phone Number: _______________
  • Alternative Phone Number: _______________

By signing this document, the individual (or their authorized legal representative) acknowledges their understanding and acceptance of the consequences of a Do Not Resuscitate Order. This decision has been discussed with a healthcare provider, and it is made voluntarily, without any external pressure.

Acknowledgement and Signature:

  • Patient (or Legal Representative) Signature: _______________
  • Printed Name: _______________
  • Date: _______________

Physician's Statement:

This section must be completed by a licensed physician, confirming that the patient (or their legal representative) has been informed about the nature and consequences of a DNR order and that this decision is consistent with the patient's current health condition.

  • Physician Name: _______________
  • Signature: _______________
  • Date: _______________
  • License Number: _______________

PDF Form Details

Fact Detail
Definition A Utah Do Not Resuscitate (DNR) Order is a legal document that instructs medical personnel not to perform cardiopulmonary resuscitation (CPR) if a patient's breathing stops or if the patient's heart stops beating.
Governing Law The Utah DNR Order is governed by the Utah Uniform Patient Decision-Making Act and is further detailed through rules and regulations provided by the Utah Department of Health.
Eligibility A DNR Order can be requested by any capable adult for themselves or for a minor child or ward for whom they are the legal guardian. Health care providers can also recommend a DNR Order for their patients under certain conditions.
Form Requirements The form must be completed accurately, including the patient's full name, date of birth, and the signature of the patient or their legal representative. A licensed health care provider must also sign the form, indicating they have discussed the order with the patient or their representative.
Recognition In Utah, a properly executed DNR Order is recognizable by an official form or a pre-approved bracelet or necklace indicating DNR status. This ensures that the order is easily identifiable by emergency personnel.
Revocation A DNR Order can be revoked at any time by the patient or their legal representative, either by physically destroying the DNR Order form, removing the DNR bracelet or necklace, or verbally expressing the desire to rescind the order to a healthcare provider.
Legal Protection Healthcare providers who follow an authentic DNR Order in good faith are afforded legal protection from liability for withholding resuscitative services according to the order.
Limitations A DNR Order does not impact the provision of other medical treatments, such as pain relief, nutrition, or hydration, unless explicitly stated otherwise in an advance healthcare directive.
Storage It is advised that the DNR Order be stored in an easily accessible location and that copies be provided to relevant healthcare providers, family members, or caregivers to ensure its directives are followed.
Additional Directives Patients are encouraged to prepare an Advance Healthcare Directive alongside their DNR Order, specifying their wishes regarding other types of medical treatment and end-of-life care preferences.

Detailed Steps for Writing Utah Do Not Resuscitate Order

Filling out the Utah Do Not Resuscitate (DNR) Order form is a critical step for those who wish to communicate their desires regarding resuscitation in the event of cardiac or pulmonary arrest. This legally binding document will guide healthcare professionals on whether to employ resuscitation techniques in such scenarios. It is essential to complete this form accurately to ensure that your wishes are clearly communicated and adhered to.

  1. Gather personal information, including your full name, date of birth, and address. This identifies who the DNR Order applies to.
  2. Consult with a healthcare professional to discuss the implications of a DNR order and ensure it aligns with your health goals and conditions.
  3. Complete the section of the form dedicated to patient details, entering your name, date of birth, and address in the respective fields.
  4. If you are unable to sign the form yourself due to physical incapacity, a legal representative may do so on your behalf. In this case, the representative's name, relationship to you, and signature must be provided.
  5. The attending physician, or an authorized healthcare professional acting under the physician's direction, must then fill out their section of the form. This includes their name, signature, and the date, certifying the issuance of the DNR Order.
  6. Review the form carefully to ensure all information is accurate and all necessary sections have been filled out and signed.
  7. Submit the completed form as directed by your healthcare provider or local health department. This may involve handing it in person or sending it through mail or fax.
  8. Keep a copy of the signed form in an easily accessible location at home, and consider carrying a wallet card indicating you have a DNR Order.
  9. Inform family members, caregivers, and close friends of the DNR Order to ensure they are aware of your wishes.

Once the form is completed and processed, it becomes a part of your medical record. It is important to revisit and review the document periodically, especially if your health status or preferences change. Updating the form to reflect any new decisions ensures that your wishes regarding resuscitation are accurately documented and respected.

Common Questions

When it comes to understanding the Utah Do Not Resuscitate (DNR) Order form, individuals might have questions about its purpose, who it's for, and how it can be implemented. Below are answers to some of the most common queries regarding this important document.

  1. What is the purpose of a Do Not Resuscitate (DNR) Order in Utah?

    The purpose of a DNR order in Utah is to instruct healthcare providers not to perform cardiopulmonary resuscitation (CPR) if a patient's breathing stops or if the patient's heart stops beating. It's an important document for those who wish to avoid aggressive life-saving procedures in favor of a more natural end-of-life process. This can be especially relevant for individuals with chronic illnesses, terminal conditions, or those who want their healthcare providers to follow specific wishes regarding end-of-life care.

  2. Who is eligible to have a DNR Order in Utah?

    In Utah, any individual can request a DNR order if they wish to forego resuscitation efforts during a medical emergency. However, the order must be signed by a licensed healthcare provider, which means the individual's physical and health status will be considered. Minors can have a DNR order, but it requires the consent and signature of a parent or legal guardian, alongside the healthcare provider's signature.

  3. How can someone obtain a DNR Order in Utah?

    • First, discuss your wish to have a DNR order with your primary healthcare provider. This professional can help assess if a DNR order aligns with your overall health status and end-of-life wishes.
    • Next, if the decision to move forward is made, your healthcare provider will fill out the necessary paperwork. In Utah, this includes a form that must be completed and signed by both the healthcare provider and the patient or their designated power of attorney.
    • Once the form is completed and properly signed, it should be placed in an easily accessible location. It's also advisable to inform close family members or caregivers of the existence and location of the DNR order.

    This process ensures that in the event of an emergency, medical personnel can quickly ascertain the patient's wishes regarding CPR and other life-saving interventions.

  4. What should be done with the DNR Order once it is signed?

    After the DNR order is signed, it is crucial to ensure it can be quickly and easily found by emergency personnel. The patient or their representative should place the document in a noticeable spot within the home, such as on the refrigerator or by the bedside. Additionally, it's wise to carry a copy on your person, perhaps in a wallet or with other important medical cards. Informing family members, caregivers, and possibly close friends about the DNR order and its location is essential so they can help communicate your wishes to healthcare professionals in an emergency.

Understanding and creating a DNR order in Utah is a significant step for individuals who wish to have their end-of-life care preferences honored. By ensuring clarity and communication around this document, individuals can have peace of mind knowing their wishes will be respected during critical moments.

Common mistakes

Filling out a Do Not Resuscitate (DNR) order in Utah is a significant step for those who wish to make their end-of-life wishes known. However, mistakes in completing this form can lead to misunderstandings, delays, and sometimes not respecting the individual's wishes. Here are ten common mistakes people often make when filling out a Utah DNR order:

  1. Not consulting with a healthcare provider: A DNR order is a medical order and needs to be discussed and signed by a qualified healthcare provider. Some individuals fill out the form without having this crucial conversation, which can lead to misunderstandings about the nature and implications of a DNR order.
  2. Missing signatures: For a DNR order to be valid, it must be signed by the patient (or their legal representative) and the healthcare provider. Skipping any of these signatures makes the order invalid.
  3. Using outdated forms: Laws and regulations change, and so do the forms. Using an outdated version of the DNR form may result in the order not being recognized.
  4. Omitting personal information: Every detail matters on a DNR order. Sometimes, people forget to include essential information, such as their full name, date of birth, or patient identification number, making the document more difficult to verify.
  5. Not specifying the conditions of the DNR: DNR orders can be conditional. If individuals have specific conditions under which they would not want resuscitation attempts, these must be clearly documented on the form.
  6. Failure to communicate with family: Not discussing the decision with family members can lead to shock, confusion, and disputes when the DNR order is discovered. It's important for family members to understand the individual's wishes.
  7. Not keeping the DNR order accessible: A DNR order needs to be readily accessible to healthcare providers in an emergency. Keeping it in a safe or another secure location where no one can find it defeats its purpose.
  8. Not updating the DNR order: People’s wishes may change, especially with new diagnoses, treatments, or changes in health status. It's important to review and update the DNR order to reflect current wishes.
  9. Misunderstanding the scope of the DNR: Some individuals think the DNR order applies to all medical treatment. It's crucial to understand that it only applies to CPR and does not affect other treatments or interventions.
  10. Not making enough copies: Individuals should make several copies of the signed DNR order. A copy should be given to the healthcare provider, kept at home, and shared with any nursing home or assisted living facility if applicable. Failing to distribute copies can lead to emergency services not being aware of the DNR order in critical situations.

To avoid these mistakes, it is advisable to have open discussions with healthcare providers, family, and possibly a legal advisor to ensure that the DNR order accurately reflects the individual's wishes and is completed and distributed correctly. Ultimately, careful attention to detail when filling out a Utah DNR order can help ensure that a person's healthcare preferences are honored in critical moments.

Documents used along the form

When someone in Utah decides to complete a Do Not Resuscitate (DNR) Order, it often accompanies other crucial documents related to their healthcare and end-of-life wishes. These documents work together to ensure a person’s medical preferences are known and respected in situations where they might not be able to communicate their wishes directly. Understanding each of these documents can help individuals and their families prepare for various healthcare scenarios.

  • Advanced Healthcare Directive - This document allows individuals to outline specific medical treatments they do and do not want to receive if they are incapacitated. It serves as a guide for healthcare providers and can include instructions on pain management, life support, and end-of-life care.
  • Medical Power of Attorney - This grants a designated person, often a family member or close friend, the authority to make healthcare decisions on behalf of the individual if they are unable to do so themselves.
  • Living Will - Similar to an advanced healthcare directive, a Living Will provides detailed instructions on end-of-life care but focuses specifically on the refusal or acceptance of life-sustaining treatments.
  • POLST Form (Physician Orders for Life-Sustaining Treatment) - This is a doctor's order that outlines a plan of care relating to end-of-life treatment, typically for seriously ill patients. It can include instructions not to resuscitate.
  • Organ and Tissue Donation Registration - This form allows individuals to register their decision to donate organs and tissues after death. It is important for making one's wishes known in advance.
  • HIPAA Release Form - This allows healthcare providers to share an individual’s health information with specified people, helping loved ones stay informed and make decisions if necessary.
  • Emergency Medical Information Form - This document provides emergency responders with critical health information, such as allergies, medications, and any existing conditions, which could be life-saving in an emergency.
  • Funeral Planning Declaration - Although not a medical document per se, this form allows individuals to outline their wishes for their funeral, including the type of service, burial or cremation preferences, and even specific arrangements.

Together, these documents offer a comprehensive approach to managing healthcare decisions and ensuring that a person’s wishes are respected and followed. They provide peace of mind to the individual and their loved ones during difficult times. Having these forms in order, along with a Utah DNR Order, ensures that medical care aligns with the patient's values and desires.

Similar forms

The Utah Do Not Resuscitate (DNR) Order form shares similarities with an Advance Directive. Both documents play crucial roles in pre-planning medical care, enabling individuals to communicate their preferences regarding the extent of medical interventions they wish to receive at the end of life or in situations where they cannot express their wishes. An Advance Directive typically covers a broader spectrum of medical decisions, including the use of life-sustaining treatments beyond resuscitation.

Comparable to a Living Will, the DNR Order specifies a critical aspect of an individual's desire for end-of-life care, notably the choice to decline cardiopulmonary resuscitation (CPR). While a Living Will contains detailed instructions on a person’s preferences for various types of medical interventions across different scenarios, including but not limited to resuscitation, the DNR Order strictly focuses on the absence of CPR in the event of cardiac or respiratory arrest.

A Power of Attorney for Health Care is another document akin to the DNR Order. It designates an agent to make healthcare decisions on behalf of an individual when they are incapacitated. While the DNR Order communicates one specific directive—no resuscitation—the Power of Attorney can encompass decisions about accepting or refusing all kinds of medical treatments, including the enforcement of a DNR.

The POLST (Physician Orders for Life-Sustaining Treatment) form also resembles the DNR Order. Both are medical orders that address critical care preferences, including resuscitation. However, POLST is broader, covering preferences for antibiotics, artificial nutrition, and more, based on a patient's current health status, making it applicable earlier in a patient’s health trajectory, not just at the end of life.

Medical Orders for Scope of Treatment (MOST) forms have similarities to the DNR Order. MOST forms provide detailed directives about a range of life-sustaining treatments, like POLST forms, and include DNR orders within a broader context of patient care preferences. They are designed to ensure patients' healthcare preferences are followed across settings, from hospitals to nursing homes.

A Health Care Proxy is somewhat similar to a DNR Order in that it involves making decisions about a person's medical care if they're unable to do so themselves. However, unlike a DNR, which specifies a single decision, a Health Care Proxy appoints someone else to make a range of healthcare decisions, including the implementation of a DNR Order based on their interpretation of the patient's wishes.

The Five Wishes document extends beyond the scope of the DNR Order by addressing personal, emotional, and spiritual needs along with medical wishes, including the person's desires about resuscitation. This comprehensive approach integrates instructions for end-of-life care within a broader discussion about comfort, dignity, and family matters.

Last Will and Testament documents, while primarily focused on the distribution of an individual's estate after death, can occasionally touch on subjects related to end-of-life care desires, albeit indirectly. Unlike the DNR, which offers a direct medical directive, a Last Will might include provisions to cover financial aspects of care preferences, such as allocating funds for hospice care, which can indirectly support a person's end-of-life wishes.

Dos and Don'ts

Filling out the Utah Do Not Resuscitate (DNR) Order form is an important step for individuals who wish to make clear their wishes regarding resuscitation in emergency situations. Here are seven dos and don'ts to help guide you through the process:

Do's:
  • Consult with a healthcare provider. Before filling out the form, have a discussion with your doctor or another qualified healthcare professional to understand fully what a DNR order means for your health and well-being.
  • Use black ink. When completing the form, make sure to use black ink to ensure that the document is legible and can be easily copied or faxed if necessary.
  • Complete all required sections. Make sure every section of the form is filled out to ensure it is legally valid. Missing information could render the document ineffective.
  • Sign in the presence of required witnesses. Utah law may require your DNR order to be signed in the presence of witnesses or a notary. Make sure you understand the requirements and follow them closely.
  • Keep the original in a safe but accessible place. Once the form is completed and signed, keep the original document in a place where it can be easily found in an emergency, such as with your personal records or with a family member.
Don'ts:
  • Don't fill it out alone if you have questions. If you're unsure about any part of the form or its implications, don't hesitate to seek advice from a healthcare provider or legal professional.
  • Don't use pencil or colored inks. These can fade over time or create issues with legibility and copying, potentially leading to confusion in an emergency situation.

Misconceptions

In discussing the Utah Do Not Resuscitate (DNR) Order form, several misconceptions frequently emerge. Clarifying these can help individuals make informed decisions regarding their end-of-life care. Here are eight common misunderstandings about the Utah DNR Order:

  • Anybody can sign up for a DNR. The reality is that DNR orders are intended for patients with serious illnesses or those nearing the end of their lives. A healthcare professional must assess and agree that CPR would not be in the patient's best interest.

  • A DNR order affects all medical treatments. This is not true; a DNR order specifically addresses cardiopulmonary resuscitation (CPR) in the event of a cardiac or respiratory arrest. It does not preclude the patient from receiving other medical treatments or interventions.

  • DNR orders are permanent. Actually, a DNR order can be revoked at any time by the patient or their legally authorized representative. Circumstances and preferences can change, and so can the applicability of a DNR order.

  • DNR means "Do not treat." This misconception leads to significant confusion. A DNR order only directs healthcare providers not to initiate CPR; it does not mean that the patient will be denied other forms of care and treatment.

  • DNR orders are only for the elderly. While it's true that older individuals often consider DNR orders, these orders apply to anyone regardless of age with a serious illness where CPR would not offer a benefit in line with their healthcare goals or values.

  • A verbal DNR is sufficient. In Utah, for a DNR order to be legally recognized, it must be documented on the official state form and signed by both the patient (or their representative) and the healthcare provider. Verbal wishes, while important, must be formalized to be actionable.

  • If you have a DNR, 911 will not assist you. This misunderstanding can deter people from obtaining a DNR. Emergency responders will always respond to a 911 call; however, if a valid DNR order is produced, they will provide comfort measures without attempting resuscitation.

  • Having a DNR order means you cannot die at home. This myth suggests that DNR orders complicate home deaths. In truth, a DNR order does not determine the place of death but rather specifies the types of intervention to be avoided at the time of death.

Understanding the nuances of DNR orders in Utah is critical for making informed healthcare decisions. By dispelling these common misconceptions, individuals and their families can better navigate their end-of-life choices.

Key takeaways

Filling out and using the Utah Do Not Resuscitate (DNR) Order Form is a crucial process for those who wish to have their preferences known in the event that they are unable to communicate these wishes due to medical conditions. Understanding the key takeaways can help ensure that the form serves its intended purpose effectively and is respected by healthcare professionals. Below are some of the most important points to keep in mind:

  • Consultation is key: Before completing a DNR order, it's essential to have a conversation with your healthcare provider. This discussion helps to ensure that you fully understand the implications of a DNR order and that it reflects your wishes accurately.
  • Proper completion and signing: The Utah DNR Order Form must be completed accurately and must be signed by both the patient (or their legal representative) and the attending physician. The signatures are a crucial step in making the document valid and legally binding.
  • Clear identification: Once completed, the DNR order should be kept in a place where it can be easily found by emergency personnel, such as attached to the refrigerator or inside the front cover of the individual’s medical records. Some people choose to wear a DNR bracelet or necklace as an additional form of identification.
  • Understanding limitations: It's important to understand what a DNR order does and does not cover. A DNR order specifically addresses the issue of not receiving cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest. It does not affect other treatments or care necessary to provide comfort or address other medical conditions.
  • Communication is crucial: Discussing your DNR order with family, close friends, and healthcare providers ensures that everyone involved understands your wishes. This proactive communication can help prevent confusion or disagreements in an emergency.
  • Review and updates: Life circumstances and medical opinions can change over time. It is advisable to review your DNR order periodically and update it if necessary to ensure it continues to reflect your current wishes.
  • Legal considerations: The Utah DNR Order Form is a legal document, and its completion has to comply with Utah state laws. Being aware of these laws and ensuring the form is completed accordingly can help avoid complications or legal challenges later on.

Understanding these key points can help individuals and their loved ones feel more comfortable and confident about the decision to complete a Utah Do Not Resuscitate Order. Remember, this form is about making your healthcare wishes known and respected, ensuring that the care you receive aligns with your preferences.

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