Hawaii Do Not Resuscitate (DNR) Order FormHawaii Do Not Resuscitate (DNR) Order Form
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HIPAA PERMITS DISCLOSURE OF POLST TO OTHER HEALTH CARE PROFESSIONALS AS NECESSARY

PROVIDER ORDERS FOR LIFE-SUSTAINING TREATMENT (POLST) - HAWAI‘I
FIRST follow these orders. THEN contact the
patient’s provider. This Provider Order form is
based on the person’s current medical condition
and wishes. Any section not completed implies
full treatment for that section. Everyone shall be
treated with dignity and respect.

A

First/Middle Name
Date of Birth

Date Form Prepared

CARDIOPULMONARY RESUSCITATION (CPR): ** Person has no pulse and is not breathing **
Attempt Resuscitation/CPR

Check
One

(Section B: Full Treatment required)

B

MEDICAL INTERVENTIONS:

Check
One

Patient’s Last Name

Do Not Attempt Resuscitation/DNAR (Allow Natural Death)

If the patient has a pulse, then follow orders in B and C.
** Person has pulse and/or is breathing **

Comfort Measures Only Use medication by any route, positioning, wound care and other measures to relieve pain
and suffering. Use oxygen, suction an