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  • (dnr) Surrogate Consent Form For Persons Without Capacity

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Resident 's Name Resident 's Room # FLORENCE NIGHTINGALE HEALTH CENTER SURROGATE 'S WRITTEN ORAL CONSENT TO THE ISSUANCE OF A DO NOT RESUSCITATE ORDER Date Resident s ID# I hereby authorize, M.D.,.

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A consent form 4 should be used when treatment decisions are being made in an adult patient's best interest due to the patient lacking capacity to make the decision themselves. Capacity means the ability to use and understand information to make a decision, and communicate any decision made.

MOLST and POLST are two acronyms defining medical orders. The MOLST is the Medical Orders for Life-Sustaining Treatment and the POLST is the Physician Orders for Life-Sustaining Treatment.

MOLST is intended for patients with serious health conditions who: Want to avoid or receive any or all life-sustaining treatment; Reside in a long-term care facility or require long-term care services; and/or. Might die within the next year.

If the patient is incompetent or otherwise cannot consent, the healthcare provider is legally bound to obtain informed consent from the incompetent patient's authorized representative, except in an emergency. This type of consent should be thoroughly documented in the healthcare record.

The MOLST form is a set of medical orders for patients with advanced illness who might die within 1-2 years; require long-term care services; or wish to avoid and/or receive specific life-sustaining treatments now.

The primary differences between the MOLST form and a DNR are: MOLST covers a variety of end-of-life treatments. A DNR only gives instructions about CPR. The MOLST form can also be used in a community setting where the DNR is intended to be used as a directive in a hospital setting.

The MOLST form is not for everyone. It is appropriate to use if you have an advanced illness, and you reach a point in your illness where your doctor would not be surprised if you died in the next year.

What should occur if the patient cannot give informed consent? If the patient is determined to be incapacitated/incompetent to make health care decisions, a surrogate decision maker must speak for her. There is a specific hierarchy of appropriate decision makers defined by state law (also see the DNR topic page).

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© Copyright 1997-2025
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232