Do Not Resuscitate (DNR) Washington (replaced by POLST)

Document name

The DNR form has been replaced by POLST (Physician’s Order for Life Sustaining Treatment) form.

Where do you get the form

You should request the form from your physician but you can see a blank form at:

http://www.wsma.org/Media/Patients-pdfs/POLST-PrintDownload.pdf

Please note that the form must be printed on terra green (a bright green color) cardstock.

Who is permitted to request the form

Any adult with an advanced life limiting illness can request the form.

Who signs the form

The physician, nurse practitioner or certified physician assistant and the patient sign the form.

How do you obtain a DNR bracelet

n/a

Revoking a DNR

n/a

Photocopy

A copy is legal.

State info link

http://www.doh.wa.gov/ForPublicHealthandHealthcareProviders/EmergencyMedicalServicesEMSSystems/DoNotResuscitate.aspx

http://www.wsma.org/wcm/For_Patients/End_of_Life/POLST/For_Patients/wcm/Patients/POLST_for_Patients.aspx?hkey=79541052-8b1b-449c-944e-5ca7f2cf7dd1

Other link

http://www.vialoflife.com/

Special notes

Order a Vial of Life decal for your front door.  The decal informs an Emergency Medical Services team that a POLST has been prepared and can found in refrigerator.

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