Utah Do Not Resuscitate (DNR) Order FormUtah Do Not Resuscitate (DNR) Order Form
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Provider Order for Life-Sustaining Treatment (POLST)
Utah Life with Dignity Order

Bureau of Health Facility Licensing and Certification, Utah Department of Health
State of Utah Rule R432-31 v3.1 February 2016 (http://health.utah.gov/hflcra/forms.php)
Patient's Last Name
Date of Birth

First Name/Middle Initial
Last 4 of SS#

U
T
A
H

Effective Date of this Order

Address (street/city/state/zip)

Medical Provider's Name (MD/DO/PA/APRN)

P
O
L
S
T

Medical Provider's Phone

Brief description of patient's
medical condition
Patient's stated goals
for medical care

A. CARDIOPULMONARY RESUSCITATION (CPR) Treatment options when the patient does not have a pulse and is not breathing (CHECK ONE)
Attempt to resuscitate (selecting attempt to resuscitate
requires selecting full treatment in Section B)

Do not attempt or continue any
resuscitation (DNR) (Allow Natural Death)

I do not wish to express a preference (selecting
this may lead to attempt to resuscitate)

B. MEDICAL INTERVENTIONS Treatme