Guide to the Illinois DNR and POLST Form

📄 Download the Official Form

You can access the official Illinois DNR/POLST form here:

👉 Download the Illinois DNR and POLST Form (fillable PDF)

What Is It?

This form is both a:

• DNR (Do Not Resuscitate) order: It tells emergency personnel not to use CPR if your heart or breathing stops.

• POLST (Practitioner Orders for Life-Sustaining Treatment): It outlines your treatment preferences across several areas (like feeding tubes, hospitalization, or ventilators).

Unlike a Power of Attorney for Health Care, this form contains direct medical orders and must be signed by both you (or your legal representative) and your healthcare provider.

When Should I Use It?

Use this form if:

• You are seriously ill, frail, or nearing the end of life.

• You want to avoid unwanted or aggressive medical interventions.

• You’ve already discussed your wishes with your doctor and want them documented in a way emergency responders will honor.

It is especially important for people with:

• Advanced illness

• Chronic conditions

• Terminal diagnoses

• A strong desire to remain at home or focus only on comfort care

What Does It Cover?

The DNR/POLST form allows you to specify:

• Whether you want CPR performed if your heart stops.

• The level of medical intervention you prefer:

  • Full treatment (including intubation and ICU care)

  • Selective treatment (IV fluids, antibiotics, etc., but not intensive care)

  • Comfort-focused care only

• Whether you want artificial nutrition and hydration, like feeding tubes.

• Where you want to receive care (home vs. hospital).

All instructions on this form are meant to be followed immediately by EMTs, emergency room staff, and all healthcare providers.

Who Needs to Sign It?

The form must be signed by:

• You, or your legal health care decision-maker

• A physician, licensed nurse practitioner, or physician assistant

No witness or notary is required.

What Do I Do With the Form?

• Keep the original in an easy-to-find location, like on your refrigerator or in your medical folder at home.

• Give copies to:

  • Your primary care doctor

  • Your agent (if you have a Power of Attorney for Health Care)

  • Family members or caregivers

  • Your local EMS or emergency responders (if possible)

• Take it with you to the hospital or long-term care facility.

Tip: Ask your doctor to add it to your electronic medical record.

Can I Change My Mind?

Yes. You can revise or cancel your DNR/POLST at any time.

• Simply fill out a new form and share it with everyone who had the old one.

• Destroy the previous copies.

• Make sure your doctor and caregivers know about the update.

DNR/POLST vs. Power of Attorney for Health Care

These two forms work well together. A POA ensures someone speaks for you; a DNR/POLST ensures your treatment instructions are followed.