DNR Order at Home in Vermont: How COLST Forms Work for First Responders

If you've documented in your advance directive that you don't want CPR or intubation, you might assume that's enough. In Vermont, it's not. Emergency first responders — EMTs, paramedics, firefighters — are legally required to administer life-saving interventions unless they see a signed clinical medical order or state-approved DNR identification. Your advance directive, no matter how clearly worded, does not qualify.

This is the single most dangerous gap in end-of-life planning, and it catches Vermont families off guard constantly.

COLST, Not POLST

Vermont does not use the national POLST (Physician Orders for Life-Sustaining Treatment) framework. The state's equivalent is the COLST — Clinician Orders for Life-Sustaining Treatment. The form was extensively updated in June 2022 and covers four treatment categories:

Section A — Cardiopulmonary Resuscitation: Applies only when the patient has no pulse and is unresponsive. Options are YES CPR or NO CPR (DNR).

Section B — Medical Interventions for Breathing: Applies during respiratory distress with an active pulse. Options include trial course, full intubation, or no intubation.

Section C — Goals of Care: Defines the overall medical intervention approach. Options are full treatment, limited or avoid-invasive treatment, or comfort-focused treatment only.

Section D — Specific Treatments: Addresses artificially administered nutrition, hydration, and antibiotics.

The COLST is a medical order, not a planning document. It must be completed and signed by a licensed clinician — an MD, DO, PA, or APRN — after an informed consent conversation with the patient or their legally authorized surrogate.

How to Get a DNR Honored at Home

Step 1: Complete the COLST form with your clinician. Schedule an appointment with your primary care physician, PA, or APRN specifically to discuss the COLST. Be prepared to state your preferences for each section. The clinician signs the form based on informed consent — or, in limited circumstances, based on clinical futility (which requires a second independent clinician to co-certify).

Step 2: Store the signed form on your refrigerator. This is the consensus recommendation in Vermont. First responders entering a home in an emergency are trained to check the refrigerator — either on the door or inside it — for the COLST/DNR form. Keep the original or a copy in a clearly visible location.

Step 3: Consider state-approved DNR jewelry. Vermont recognizes wearable DNR identification — bracelets or necklaces — that first responders are trained to check. However, you can only purchase approved jewelry from two vendors: StickyJ Medical ID or MedicAlert Foundation. Both require you to submit a copy of your signed COLST form before they'll process the order. Jewelry costs range from approximately $25 to $100 depending on style and vendor.

The COLST Does Not Go in the Registry

The Vermont Advance Directive Registry (VADR) is designed for advance directives only. COLST forms are not eligible for registration. This is another common point of confusion — people upload their COLST to the VADR thinking it's covered, but the registry won't store it and hospitals won't find it there.

The COLST should be:

• Posted on your refrigerator at home
• Kept in your medical file with your primary care provider
• Carried with you (as a copy) if you travel between care settings
• Communicated to any home health aides or visiting nurses

When a Surrogate Can Request a COLST

If a patient already lacks capacity and has no advance directive or healthcare agent, there's a narrow pathway under 18 V.S.A. § 9731. The clinician can work with "interested individuals" — family members or close friends — to designate a single surrogate specifically for DNR/COLST decisions. Everyone available must agree on who the surrogate will be, and the clinician documents this consensus in the medical record.

This is the only general medical decision that Vermont allows without a formal advance directive or court-appointed guardian. All other treatment decisions for incapacitated patients without agents require ethics committee consultation or guardianship proceedings.

COLST and Advance Directive Work Together

Think of the two documents as covering different timescales:

• The advance directive is your long-term planning document. It names your healthcare agent, records your treatment values, and guides decisions during hospitalization and long-term care.
• The COLST is your emergency standing order. It tells first responders exactly what to do in the first minutes of a crisis at home.

Without both, there's a gap. The advance directive covers hospitals and care facilities but not emergency scenes. The COLST covers emergency scenes but doesn't name a decision-maker for ongoing care.

The Vermont Advance Directive & Living Will Kit includes a COLST coordination guide that helps you prepare for the clinical conversation and integrate your emergency orders with your long-term advance directive.

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