Utah Do Not Resuscitate FormUtah Do Not Resuscitate Form
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Utah Department of Health
Bureau of Health Facility Licensing, Certification and Resident Assessment

Physician Order for Life Sustaining Treatment
Utah Life with Dignity Order
Version 2 – 9/09

State of Utah Rule R432-31
(http://health.utah.gov/hflcra/forms.php)
This is a physician order sheet based on patient wishes
and medical indications for life-sustaining treatment. Place
this order in a prominently visible part of the patient’s
record. Both the patient and the physician must sign this
order (two physicians must sign if the patient is a minor
child). When the patient’s condition makes this order
applicable, first follow this order, and then, if necessary,
contact the signing physician.

Last Name of Patient:

First Name/Middle Initial:

Date of Birth:

Physician’s Name:
Effective Date of this Order:

Physician’s Phone:

(IF NOTHING IN A SECTION IS CHECKED, CAREGIVERS SHOULD PROVIDE THE FULLEST TREATMENT DESCRIBED IN THAT
SECTION UNLESS THAT TREATMENT DIRECTLY CONFLICTS WITH A TRE