What should be included in a sample consent form for Do Not Intubate (DNI) and Do Not Resuscitate (DNR) orders?

Sample Consent Form for Do Not Intubate (DNI) and Do Not Resuscitate (DNR) Orders

A valid DNR/DNI consent form must be written, signed by a physician, and include explicit documentation of the patient's wishes regarding specific emergency interventions to be legally binding and effective in guiding care during end-of-life situations. 1

Essential Components of DNR/DNI Consent Form

Patient Information

• Full legal name, date of birth, and medical record number 1
• Date of DNR/DNI order implementation 2, 1
• Clear statement of patient's capacity at time of decision-making 2

Specific Interventions to be Withheld

• Clear designation of "Do Not Resuscitate" (DNR) or "Do Not Attempt Resuscitation" (DNAR) or "Allow Natural Death" (AND) 3
• Explicit statement regarding intubation status (Do Not Intubate) 4
• Specific instructions about which interventions are to be withheld: 1
  • Cardiopulmonary resuscitation (CPR)
  • Defibrillation
  • Endotracheal intubation
  • Mechanical ventilation
  • Vasopressors
  • Other specific interventions

Interventions Still Permitted

• Statement clarifying that DNR/DNI orders do not affect other treatments unless specifically noted 2, 1
• Explicit list of interventions that may continue (as applicable): 1
  • Supplemental oxygen
  • Intravenous fluids
  • Pain management
  • Antibiotics
  • Other comfort measures

Documentation of Discussion

• Record of discussion with patient and/or surrogate decision-maker 2, 1
• Documentation of patient's values, goals, and preferences 2
• Medical rationale for DNR/DNI order 1
• Names of family members or surrogates present during discussion 1

Signatures and Verification

• Patient signature (if capable) 2
• Surrogate decision-maker signature (if patient lacks capacity) 2
• Physician signature with printed name and contact information 1
• Witness signatures (at least one, preferably two) 2
• Date and time of signatures 1

Review and Renewal Information

• Statement indicating when order should be reviewed (e.g., with significant change in condition) 1
• Process for revoking or modifying the order 2
• Statement that order remains in effect unless explicitly revoked 1

Important Considerations for DNR/DNI Forms

Legal Requirements

• Forms must explicitly state they apply even when life is at risk 2
• Must be written, witnessed, and clearly state applicability to life-sustaining treatment 2
• Should use current terminology - "DNAR" (Do Not Attempt Resuscitation) or "AND" (Allow Natural Death) is preferred over "DNR" as it creates a better emotional environment to explain the meaning 3

Scope Clarification

• Clear statement that DNR/DNI orders are not advance directives but specific medical orders 2
• Explanation that DNR/DNI status does not limit other appropriate treatments 2
• Statement that the order can be suspended for procedures when appropriate 2

Common Pitfalls to Avoid

• Ambiguous language about which interventions are to be withheld 1
• Failure to specify which interventions are still permitted 1
• Lack of documentation about discussions with patient/family 1
• Oral orders without written documentation (not acceptable) 1
• Partial DNR orders that may cause confusion during emergencies 4

Periodic Review

• Statement indicating when the order should be reviewed (e.g., with significant change in condition) 1
• Documentation of any subsequent reviews and reaffirmations of the order 1

By including these elements in a DNR/DNI consent form, healthcare providers can ensure that patients' wishes regarding end-of-life care are clearly documented and respected while avoiding confusion during emergency situations.