Minnesota Do Not Resuscitate Form - Free Download
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MINNESOTA DEPARTMENT OF VETERANS AFFAIRS
MN Veterans Homes
POLICY: Do Not Resuscitate
OBJECTIVE: The Minnesota Veterans Homes will respect the rights and wishes of residents or their proxies
to choose treatment measures in the event of a life threatening event.
Cardio-Pulmonary Resuscitation (CPR): CPR is a medical process that includes airway management,
ventilatory assistance, chest compressions, defibrillation, and drug therapy as defined by the American Heart
Do Not Resuscitate (DNR): In the event of an acute cardiac or respiratory arrest, no CPR measures will be
initiated. A DNR order does not require a terminal prognosis and it may stand alone as an order.
Health Care Directive: A document that enables residents to provide health care instructions
to guide health care providers, other assisting health care providers, family members and health care alternative
decision makers in making health care decisions on the residents’ behalf in the event that the he/she cannot
make decisions for him/herself. This document also allows the resident to name another person (proxy) to make
health care decisions if the resident is unable to decide or speak for him/herself in the judgment of the attending
Proxy: A person empowered to act for another. In the event that a resident is unable to make decisions
regarding his care because of a cognitive, mental, or physical impairment, a proxy will be identified to represent
the resident in making clinical decisions. The proxy may be a formal, legal proxy, which includes a court
appointed guardian or conservator or a proxy identified in the resident’s healthcare directive. An informal
proxy is a person chosen because she or he is knowledgeable about the resident’s wishes. Usually the informal
proxy is a close family member or person significantly involved with the resident. (See Alternative Decision-
Primary signs of death include; dilated, non-reactive pupils, absence of respirations, no perceptible pulse/heart
beat and absence of blood pressure, beginning or post-mortem rigidity, waxy pallor, cyanosis or mottling of
dependent body parts, skin cold to touch.
Comfort Care Plan: When medical treatment is deemed to be unable to attain the goals and benefits of
medical, psychological and spiritual healthcare and quality of life, and the values, beliefs and expectations of
the resident or proxy, a Comfort Care Treatment Plan will be implemented. Comfort care is medical treatment
that is aimed at providing symptom management and comfort rather than curative or life prolonging care. The
resident or proxy may request a limiting of treatment so that comfort is the goal of care. The interdisciplinary
health care team may recommend comfort care. To enact the comfort care order, any mechanical intervention
that had been initiated to support life and is determined by the physician to prolong the resident’s dying process
will be withdrawn. The physician, in consultation with the resident or proxy, may order whatever medical
procedures are necessary and appropriate for resident comfort.
Do Not Resuscitate