January - February 2023

It’s a New Year – Answers to some New (and Old) Questions about Advance Directives and DNR/COLST Orders

VEN receives questions from community members, providers, and facilities daily. Below are answers to some of the most common questions we received in January.

Have a question for us? Send them to ven@vtethicsnetwork.org to receive a direct reply.

Is an additional HIPAA release necessary with an advance directive?

No. An additional HIPAA release is not necessary nor required.

HIPAA (Health Insurance Portability & Accountability Act) is a federal law that protects patient information from being shared beyond your health care team. It is a common misconception that the health care agents appointed in your advance directive need to receive an additional HIPAA release to make health care decisions on your behalf.

In fact, the advance directive statute specifically includes permissions for agents to have access to your health information when they are needed to make decisions. The full statutory language is below:

In practical terms, this means that a properly signed and witnessed advance directive is its own HIPAA release. It grants permission for your appointed agents to view medical records, discuss your care with your physicians, and serve as an advocate for your health care rights. 

I completed an advance directive and DNR order with my doctor in another state. Now that I live in VT, will they be honored?

Yes. Vermont’s advance directive law has a ‘reciprocity clause’ which means that any directive completed properly in another state will be honored in Vermont. This is true for both advance directives and medical orders like DNR/COLST (also called MOLST, POLST, etc. in other states).

Your out-of-state directive can even be registered with the Vermont Advance Directive Registry. Simply attach a copy to a completed VADR Registration Agreement/Change form, and submit via mail, fax or email. Just be sure to include your new Vermont address on the VADR form. More information on the VADR.

I heard that there is a new DNR/COLST form. Do I need to redo my DNR on the new form?

No. Existing DNR/COLST orders do NOT need to be put onto new forms unless there is a change to the order. If you are interested to learn more about the most recent requirements for DNR/COLST, check out our informational session recording.

Should a patient's code status be documented on a DNR/COLST order if the plan is to attempt resuscitation?

No. The provision of CPR (i.e “full code”) is the standard of care absent a DNR/COLST order. Meaning, if a person’s heart stops and they are not breathing (cardiopulmonary arrest), CPR (cardiopulmonary resuscitation) will be administered UNLESS there is a valid DNR/COLST order present. If the individual does not have limitations, no order should be completed. It is problematic to use the DNR/COLST form exclusively as a tool to record the code status for all individuals, particularly those who want all life-saving interventions.

DNR/COLST orders are portable orders intended for persons who are at risk of a life-threatening clinical event due to a serious life-limiting medical condition. While the form includes code status orders, it also includes orders to address other interventions that should be provided or withheld, regardless of preferences surrounding CPR. In the absence of explicit orders for do not resuscitate (DNR), the default treatment is always for full-code

status—which includes CPR and intubation. A DNR/COLST order is unnecessary for individuals who want to receive the most aggressive and potentially life-sustaining treatment.

For further reading about some common pitfalls of portable medical orders (COLST/POLST/MOLST) best avoided:

POLST Is More Than a Code Status Order Form: Suggestions for Appropriate POLST Use in Long-Term Care

POLST: The Seven Deadly Sins

Advance Care Planning and POLST: Promise and Pitfalls

VEN’s Training on the 2022 Vermont DNR/COLST

Are you a health care provider? Get Access to the Vermont Advance Directive Registry Today!

Vermont healthcare providers can receive authorized user access to query the registry for patient directives. This is an important step in supporting your patients in advance care planning conversations and ensures that you have access to the most current health planning documents when you need them. 

Application Form & Instructions

Palliative Care and Pain Management Task Force Report

The Palliative Care Task Force was created in 2009 with a goal of coordinating palliative care initiatives across the state, providing ongoing education to health care clinicians and consumers about palliative and end-of-life care, as well as ensuring access to those services when needed.

2023 Legislative Recommendations

  • Make Permanent Remote Witnessing and Explaining of Advance Directives: The COVID pandemic necessitated numerous modifications to health care delivery and gave rise to the development of improved telehealth services. It also prompted an increase in conversations about future health care needs should an individual lose capacity to make decisions for themselves. Promoting meaningful advance care planning conversations and the completion of advance directive documents is a hallmark of quality patient-centered care. While remote witnessing and explaining of advance directives was initially intended to be a temporary provision to ensure uninterrupted access to advance directive completion, the success of this option, as it relates to expanded access to document completion, leads the Task Force to recommend this become a permanent provision of Vermont’s advance directive statute.

  • Include Remote Witnessing and Explaining for Ulysses Clause: Under the existing statute an individual may include a provision in their advance directive that permits their health care agent, in the event that the principal lacks capacity, to authorize or withhold health care over the principal’s objection (i.e. Ulysses Clause). [See 18 VSA §9707(h)]. This can be an important component of an advance directive for individuals with certain health care considerations. To be valid this provision necessitates additional signing, witnessing and explaining. In the original remote witnessing and explaining permissions, the inclusion of a Ulysses Clauses was not explicitly addressed or included. In making permanent the option to execute an advance directive via remote witnessing and explaining, the Task Force recommends the legislature make explicit that this shall also apply to the completion of a Ulysses Clause provision.

  • Allow for Electronic Signatures for Advance Directive Completion: In conjunction with remote witnessing and explaining, the Task Force is recommending the allowance of e-signing of advance directive documents to further enhance access to document completion and submission to the Vermont Advance Directive Registry. 3 The remainder of this report provides highlights from local, regional, and statewide agencies/initiatives directed toward advancing these efforts.

Read the Full Report

Upcoming Events

  • Register Now for the Respecting Choices ACP National Courses (Live Interactive Webinars)
  • Because ACP is not a one-size-fits-all conversation, Respecting Choices courses are tailored to help you meet the needs of the individuals you work with based on their stage of health.
  • Throughout February, March, April and May, Respecting Choices is offering a series of Facilitator and Instructor certification courses for individual who support advance care planning in the community. Continuing Education credits are available.

Save the Date

  • The 53rd Meeting of the NH/VT Ethics Committee: Professional Responsibility, Ethics & Advocacy - Skills to Empower Effective Change.
  • This will be an in-person meeting on Thursday, April 13, 2023 at Dartmouth Hitchcock Medical Center in Auditoria E&F. VEN will lead a pre-meeting gathering for ethics committee members from Vermont’s hospitals to hear about relevant legislative updates, share information, discuss needs and reconnect with colleagues from across the state. The formal program will be from 12:30 - 3:45 with lunch provided.
  • Registration information will be posted on our website.
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