North Dakota Do Not Resuscitate (DNR) Order FormNorth Dakota Do Not Resuscitate (DNR) Order Form
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HIPAA PERMITS DISCLOSURE OF POLST TO OTHER HEALTH CARE PROVIDERS AS NECESSARY FOR TREATMENT

North Dakota POLST: Physician Orders for Life Sustaining Treatment
Physician Orders
for Life-Sustaining Treatment (POLST)

Patient’s Last Name
FIRST follow these orders, THEN Call the appropriate medical contact.
These medical orders are based on the patient’s medical condition
Patient’s First Name/Middle Initial
and wishes. Any section not completed implies full treatment for that
section. Everyone shall be treated with dignity and respect.

A
B

Check
One

Check
One

Patient’s Date of Birth (mm/dd/yyyy)

CARDIOPULMONARY RESUSCITATION (CPR): Patient has no pulse and is not breathing.

CPR/ATTEMPT RESUSCITATION

DNR/DO NOT ATTEMPT RESUSCITATION (Allow Natural Death)

When not in cardiopulmonary arrest, follow orders in B and C.

MEDICAL INTERVENTIONS: Patient has pulse and/or is breathing.
Comfort Measures always provided regardless of level of care chosen.

COMFORT MEASURES ONLY - Use me