How to Fill Out a Utah Do Not Resuscitate (DNR) Order Form

Utah’s do-not-resuscitate order is part of the state’s Provider Order for Life-Sustaining Treatment, known as the POLST or Life with Dignity Order. To create a valid Utah DNR form, you complete the POLST with your physician, advanced practice registered nurse, or physician assistant, sign it together, and keep it somewhere a paramedic can spot it within seconds. The form is free, and once signed it becomes a medical order that EMS and hospital staff are required to follow.

Who the Form Is Meant For

The POLST is not a precautionary document every adult should fill out. It is a medical order built for people already facing a serious health situation. Utah’s administrative rules direct healthcare facilities to offer the form to people with a serious illness who are likely to face a life-threatening crisis, people with declining cognitive abilities who have no surrogate or guardian, and people with specific preferences about end-of-life treatment.¹ If you are healthy and simply want your general wishes recorded, an advance directive is the usual tool. The POLST is for the stage when a crisis is foreseeable.

Any adult with health care decision-making capacity can sign the form.² If you cannot, it can be signed on your behalf by the person highest in Utah’s surrogate hierarchy: a health care agent you previously appointed, then a court-appointed guardian, then the highest-priority default surrogate, typically a spouse, then adult children, then parents.³ For a minor, a parent or guardian signs, and two physicians must certify that withholding life-sustaining treatment is in the child’s best interest.

Where to Get the Form

Only the official form designated by the Utah Department of Health and Human Services counts. You can download it from the DHHS website or request a copy from any licensed healthcare facility. The document itself costs nothing. Your provider may bill for the office visit where you discuss your wishes, but the form is free.

Filling Out the Four Sections

Your provider prepares the form based on a conversation with you about your medical situation and your preferences. Complete every section. If you don’t want to express a preference on a particular section, mark that choice rather than leaving the section blank, because a blank line can be read as missing information.⁴

Section A: CPR

This is the DNR decision itself. You pick either “Attempt Resuscitation” or “Do Not Attempt Resuscitation.” The choice applies only when you are found pulseless and not breathing. Selecting “Do Not Attempt Resuscitation” means no chest compressions and no defibrillators, including automated external defibrillators.⁴ If you choose “Attempt Resuscitation” here, you must choose “Full Treatment” in Section B, because resuscitation can involve intubation, mechanical ventilation, and vasopressors.

Section B: Medical Interventions

Section B governs what happens when you still have a pulse but are in a medical crisis. You pick one of three levels.

Full Treatment covers all medically effective interventions, including intubation, mechanical ventilation, defibrillation, cardioversion, and vasopressors.
Limited Additional Interventions permits IV fluids and medications but no intubation or mechanical ventilation. You can also specify whether you want hospital transfer.
Comfort Measures focuses on pain and symptom relief. IV antibiotics and fluids are generally not considered comfort measures and would require choosing Limited or Full. Some IV medications for pain, nausea, or delirium may still be given under Comfort Measures.⁴

You can select DNR in Section A and still choose Full Treatment in Section B. That combination says you do not want CPR if your heart stops but you do want aggressive care as long as you still have a pulse. People often assume the two sections have to match. They don’t.

If you never want to be brought back to a hospital, write that in the “other instructions and clarifications” area.

Section C: Artificial Nutrition

Here you say whether you want long-term artificial nutrition, a time-limited trial, or none at all. This covers feeding tubes and IV nutrition.

Section D: Patient Preferences

Section D records how much authority your surrogate has to modify treatment decisions on your behalf. Only you can complete this section, and only while you have decision-making capacity.⁴ A surrogate cannot fill it in for you. You also note here whether you have a separate advance directive on file.

Signing the Form

Two signatures make the form valid. Your physician, APRN, or physician assistant must sign personally, and you (or your authorized surrogate) must also sign.² Without both signatures, EMS will default to full resuscitation.

Electronic signatures are acceptable.¹ If a surrogate cannot sign in person or electronically, a verbal authorization works when it is confirmed by two medical professionals caring for the patient. Photocopies and faxes of signed forms are legally valid, so you can distribute copies to family and healthcare facilities without worrying that only the original counts.

Where to Keep the Signed Form

The form’s instructions say to put it somewhere prominently visible in your home or your medical record.⁴ The front of the refrigerator and the wall near the head of the bed are the two most common spots. EMS responders arriving at a cardiac event have seconds to find the document. If they can’t, they are trained to begin resuscitation immediately.

A copy must travel with you between care settings, including trips to the emergency department.⁴ In licensed healthcare facilities, the form belongs in your medical record, and staff must present it to EMS when they arrive.⁵ Tell family members and caregivers exactly where it is. The most common reason a valid order gets ignored is that nobody could find the paperwork in time.

DNR Bracelets and Necklaces

Utah also recognizes Life with Dignity bracelets and necklaces from vendors approved by the Department of Health and Human Services. They are color-coded: purple means do not attempt resuscitation, yellow means attempt resuscitation. Each piece must display “Utah EMS Life with Dignity Order” along with your name.⁶

Responders who see the jewelry will still look for the actual POLST to confirm the details of your treatment choices. If they can’t find it, the color alone is enough to establish the legal presence of a valid order matching that code.⁶ Either way, EMS personnel may still provide measures to keep you comfortable.

Changing or Revoking the Order

You can change your mind at any time. To update your preferences, complete a new POLST with your provider. The most recently dated form automatically supersedes earlier versions.⁴ To revoke the form entirely, draw a line through Sections A through D, write “VOID” in large letters across the form, and sign and date it. Destroy or clearly mark any other copies so an outdated version doesn’t surface in an emergency.

If you gave your surrogate authority in Section D to modify treatments, that person can adjust the POLST in collaboration with your medical provider, as long as the changes stay consistent with your known preferences.

If You Move or Travel

Utah’s rules allow EMS and other providers to honor a POLST or similar form from another state if it is substantially similar to Utah’s and was executed under that state’s laws.⁷ The word “may” matters. Providers have discretion, and an unfamiliar out-of-state form can create confusion in a fast-moving emergency. If you’ve moved to Utah permanently, completing a new Utah POLST with a local provider removes the ambiguity.

Carrying a Utah form into another state is less predictable. Each state sets its own rules on recognizing out-of-state orders, and there is no federal law requiring reciprocity. A copy of your Utah form is better than nothing, but talk to a local provider anywhere you spend significant time.

1
Utah Office of Administrative Rules. Utah Administrative Rule R432-31 – Current Rules
2
Utah Legislature. Utah Code 75A-3-106 – Emergency Medical Services – Order for Life Sustaining Treatment
3
Utah Legislature. Utah Code 75A-3-206 – Surrogate Priority
4
Utah Department of Health. Provider Order for Life-Sustaining Treatment (POLST) Utah Life with Dignity Order
5
Utah Department of Health. Emergency Medical Services Do Not Resuscitate – Section: R426-100-3
6
Utah Department of Health. Emergency Medical Services Do Not Resuscitate – Section: R426-100-7
7
Utah Office of Administrative Rules. Utah Administrative Rule R432-31 – Section: R432-31-11