Washington Do Not Resuscitate (DNR) Order FormWashington Do Not Resuscitate (DNR) Order Form
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HIPAA PERMITS DISCLOSURE OF POLST TO OTHER HEALTH CARE PROVIDERS AS NECESSARY

Physician Orders for Life-Sustaining Treatment (POLST)
FIRST follow these orders, THEN contact physician, nurse practitioner
or PA-C. The POLST is a set of medical orders intended to guide
medical treatment based on a person’s current medical condition
and goals. Any section not completed implies full treatment for that
section. Completing a POLST form is always voluntary. Everyone shall
be treated with dignity and respect.

Last Name - First Name - Middle Name or Initial
Last 4 #SSN (optional)

Date of Birth

Agency Info/Sticker

Medical Conditions/Patient Goals:

A
Check
One

B
Check
One

Cardiopulmonary Resuscitation (CPR): Person has no pulse and is not breathing.

When not in cardiopulmonary arrest, go to part B.

Attempt Resuscitation/CPR

Do Not Attempt Resuscitation/DNAR (Allow Natural Death)
Choosing DNAR will include appropriate comfort measures.

Medical Interventions: Person has pulse and/or i