Consulting physician confirms diagnosis, prognosis and capacity for a patient under Vermont's Patient Choice at End of Life law.
- Completed by
- Consulting physician
- Issued by
- Vermont Department of Health
- Format
- Language
- English
Vermont DNR/COLST Form: Clinician Orders
Vermont uses one state form, effective June 2022, for both out-of-hospital Do Not Resuscitate orders and clinician orders for life-sustaining treatment such as intubation, nutrition, hydration and antibiotics. Under 18 V.S.A. 9708, EMS and facilities honor it. Clinicians complete it through shared decision-making with the patient or agent, and in hospitals it is used only when a patient is discharged with a treatment limitation.
Who completes it
A clinician (MD, DO, APRN or PA) completes and signs Sections A to C and, separately, Section D. A DNR order rests on informed consent from the patient, agent, guardian or surrogate, or on futility certified by a second clinician.
Submitting and payment
- How to submit it
- Nothing is filed; the patient keeps the order clearly displayed at home, for example on the refrigerator, and brings a copy on admission. Photocopies and faxes of signed forms are legal and valid.
- Who pays
- Patients pay for optional DNR ID jewelry from the two approved vendors: MedicAlert charges an annual fee and offers financial assistance, while StickyJ has no annual fee.
Good to know
- For a patient in a health care or residential care facility, the clinician must initial that the facility's DNR protocol requirements have been met.
- Verbal orders: the nurse or social worker prints the clinician's name, writes Verbal Order, signs, and a duplicate goes to the clinician for an original signature.
- Review at least annually, more often in residential or inpatient settings, and on transfer or a change in health or preferences. Prior approved Vermont forms remain valid.
- Properly completed MOLST or POLST orders from other states are honored in Vermont, but out-of-hospital orders written in Vermont must use the Vermont form.
Get the official form
Download the current version from the source each time; forms change without notice.
Vermont DNR/COLST Form (Do Not Resuscitate / Clinician Orders for Life-Sustaining Treatment)
Fill it with Vero
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
How this list is checked
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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Frequently asked questions
Does a Vermont DNR/COLST expire?
No. Properly executed orders do not expire, but they should be reviewed periodically, at least annually and more often in residential or inpatient settings, and when the patient changes care setting, health status or preferences. To void all or part, draw a line through it and write VOID.
Can a Vermont DNR be written without the patient's consent?
Yes, on the basis of medical non-benefit, or futility, which is required when there is no consent. The clinician and a second clinician must both certify that resuscitation would not prevent the patient's imminent death if cardiopulmonary arrest occurred, and the second clinician signs Section A.