Code of Vermont Rules
Agency 13 - AGENCY OF HUMAN SERVICES
Sub-Agency 140 - DEPARTMENT OF HEALTH
Chapter 066 - ADVANCE DIRECTIVES FOR HEALTH CARE RULES
Section 13 140 066 - ADVANCE DIRECTIVES FOR HEALTH CARE RULES
Universal Citation: VT Code of Rules 13 140 066
Current through February, 2024
Section 1.0 Authority
These rules are adopted pursuant to 18 V.S.A. §§ 9708 and 9719.
Section 2.0 Purpose
The State of Vermont recognizes the fundamental right of an adult to determine the extent of health care they will receive, including treatment provided during periods of incapacity and at the end of life. 18 V. S.A., ch. 231 enables adults to retain control over their own health care through the use of Advance Directives, including appointment of an agent and directions regarding health care and disposition of remains.
Section 3.0 Definitions
In addition to the definitions at 18 V.S.A. § 9701, the following definitions apply to this rule. Several definitions from 18 V.S.A. § 9701 are repeated in this rule or expanded upon for clarity or efficient reference.
3.1 "Advance Care Planning Documents" means
documents for creating, registering, amending, suspending or revoking an
Advance Directive or for creating a DNR/COLST.
3.2 "Advance Directive" means a written
record executed pursuant to
18 V.S.A. §
9703. It may include appointment of an agent,
identification of a preferred primary clinician, instructions on health care
desires or treatment goals, an anatomical gift as defined in 18 V.S.A. §
5238, disposition of remains, and funeral goods and services. The term includes
documents designated under prior law as a durable power of attorney for health
care or a terminal care document. Although a specific form is not required to
execute an Advance Directive, a suggested form, and related information, is
posted on the Department's website.
3.3 "Vermont Advance Directive Registry" or
"VADR" means the secure, web-based database to which Vermont residents may
submit, at no charge, their Advance Directive. VADR documents for submitting,
amending, suspending or revoking Advance Directives are as follows:
Document A VADR Registration Agreement
Document B VADR Authorization to Change
Advance Care Planning Documents and VADR documents are available on the Department's website. As used in this rule, the terms VADR and Registry also include the business processes and staff in place to administer the VADR system and ensure that the system's operations are current and conform to 18 V. S.A., ch. 231.
3.4
"Clinician" means a medical doctor (MD), an osteopathic physician (DO), an
advance practice registered nurse (A.P.R.N.), or a physician assistant (P.A.)
licensed or certified under the laws of the State of Vermont and acting within
the scope of that license or certification or an MD, DO, APRN or PA who treated
a patient outside of Vermont and held a valid licensed to practice in the state
in which the patient was located at the time the DNR/COLST was
issued.
3.5 "Clinician Orders for
Life-sustaining Treatment" or "COLST" means a clinician's order or orders for
treatment or limitation of treatment such as intubation, mechanical
ventilation, transfer to hospital, antibiotics, artificially administered
nutrition, or other medical intervention. A COLST order is designed for use in
outpatient settings and health care facilities and may include a DNR order that
meets the requirements of
18
V.S.A. §
9708.
3.6 "Department" means the Department of
Health.
3.7 "Do- Not- Resuscitate
order" or "DNR order" means a written order by the patient's clinician
directing health care providers not to attempt resuscitation.
3.8 "DNR Identification" means a necklace,
bracelet, or anklet identifying the patient as an individual who has a DNR
order.
3.9 "File" means information
and documents submitted to the Vermont Advance Directive Registry (VADR)and
accessible to authorized persons and entities, including the registration
information, Advance Directive, and any amendment, suspension or revocation of
an Advance Directive.
3.10
"Provider" means a health care provider, health care facility, residential care
facility, funeral director, crematory operator, cemetery official, organ
procurement organization, probate court official, and employees
thereof.
3.11 "Registrant" means a
principal who has submitted an Advance Directive to the Vermont Advance
Directive Registry as described in Section
5.0 of this rule.
Section 4.0 Advance Directives
4.1 Once an Advance Directive is in effect,
the following entities shall follow its instructions regardless of the form of
the Advance Directive: agents, guardians, health care providers, health care
facilities, residential care facilities, funeral directors, crematory
operators, cemetery officials and persons appointed to arrange for the
disposition of a principal's remains. Information about Advance Directives and
related documents will be available on the Department's website.
4.2 A principal may execute any or all parts
of any Advance Directive.
Section 5.0 Vermont Advance Directive Registry (VADR)
5.1 The submission of Advance Care Planning
Documents to VADR is voluntary. Registrants who voluntarily use VADR have a
responsibility to keep the VADR informed and updated about any changes to their
Advance Directive. This responsibility is important because medical providers
and facilities are required to access the VADR system for information about a
person's Advance Directive, and information obtained from VADR presumed to be
current and accurate absent any evidence to the contrary.
5.2 VADR serves only as a repository of
information and documents. The validity of documents will not be evaluated
except to determine whether the Registration Agreement is complete.
5.3 Submitting documents to VADR
5.3.1 Any principal may submit a copy of an
Advance Directive and an original Registration Agreement (Document A) for entry
into the registry by mailing, e-mailing, or faxing those documents to VADR.
Addresses for submitting these forms are available on the Department's
website.
5.3.2 An e-mailed Advance
Directive must be submitted in a pdf format.
5.3.3 VADR staff will mail the registrant a
confirmation of the submission, a unique identification number, a wallet card
and stickers with VADR contact information, and instructions for accessing VADR
to view the file.
5.4
Amending, Suspending, or Revoking an Advance Directive
5.4.1 To amend an Advance Directive, a
registrant shall complete a new Advance Directive that is properly signed and
witnessed pursuant to
18 V.S.A. §
9703. The new Advance Directive can be filed
with VADR by using the Authorization to Change form (Document B).
5.4.2 A registrant may suspend or revoke an
Advance Directive at any time by notifying VADR staff in writing or by e-mail
with the registrant's identification number, or sufficient information to
identify the registrant, and a completed VADR Authorization to Change form
(Document B) indicating the action the registrant is taking.
5.4.3 Upon receiving an amendment, suspension
or revocation of an Advance Directive, the registrant's file will be updated in
VADR.
5.4.4 Each registrant will
receive an annual notice from VADR requesting the registrant review the
information on file. It is each registrant's responsibility to review this
notice and their Advance Directive to make sure it reflects their wishes by
being accurate and current.
5.4.5
Failure to file an amended Advance Directive or notify VADR of a suspension or
revocation of an Advance Directive could result in medical providers and
facilities following the instructions of the latest Advance Directive on file
with the registry.
5.4.6 The most
recently dated and signed version of an advanced directive is the most current
one that shall be honored by professionals, regardless of how long ago it was
signed.
5.5 Notification
of VADR by health care providers, health care facilities, and residential care
facilities. 5.5.1 A clinician, health care provider, health care facility, or
residential care facility who becomes aware of an amendment, suspension, or
revocation of an advance directive while treating an incapacitated principal
shall make reasonable efforts to:
5.5.1.1
Confirm the amendment, suspension, or revocation;
5.5.1.2 Record the amendment, suspension, or
revocation in the principal's medical record;
5.5.1.3 Flag the amendment, suspension, or
revocation in the principal's medical record on the front of the medical folder
or on the front of any advance directive filed in the medical record;
5.5.1.4 Notify the principal, agent, and
guardian of the amendment, suspension, or revocation; and
5.5.1.5 Inform the registry of the amendment,
suspension, or revocation.
5.5.2 A
clinician, health care provider, health care facility, or residential care
facility who becomes aware of an amendment, suspension, or revocation of an
advance directive while treating a principal with capacity shall comply with
the following requirements:
5.5.2.1 Satisfy
the requirements of Sections 5.5.1.1, 5.5.1.2 and 5.5.1:3; and
5.5.2.2 On request, assist the principal in
notifying agents, guardians, interested individuals, and the
registry.
5.5.3 A health
care provider, health care facility, or residential care facility not currently
providing health or residential care to a principal who becomes aware of an
amendment, suspension, or revocation of an advance directive shall ensure that
the amendment, suspension, or revocation is recorded and flagged in the
principal's medical record and is submitted to the
registry.
5.6
Notification by an Agent/Guardian
5.6.1 An
agent, as defined by
18 V.S.A. §
9701(2), or guardian who
becomes aware of an amendment, suspension, or invocation of a registrant's
advance directive shall make reasonable efforts to notify VADR of an amendment,
suspension, or revocation by completing and sending a VADR Authorization to
Change (Document B) if the patient's advance directive has been submitted to
the VADR.
5.6.2 Failure to notify
VADR of an amendment, suspension, or revocation of an advance directive does
not affect the validity of the amendment, suspension, or revocation of an
advance directive.
Section 6.0 Access to the Registry
6.1 No
person shall access VADR information for any purpose unrelated to
decision-making for health care or disposition of remains of the registrant,
except that the Department may authorize specific persons to access the
information for statistical or analytical purposes as long as adequate
assurances exist that registrants' identifying information remains
confidential. (
18 V.S.A. §
9719(b) (1) ).
6.2 Advance directives can be accessed on the
Department's website by using the unique registration identification number
issued to the registrant by the VADR.
6.3 Agents, guardians, persons appointed to
arrange for the disposition of remains, or any person to whom the registrant
has given the registrant's identification number and authority to access the
file, may access the registrant's file by using the registrant's identification
number.
6.4 An agent, guardian, or
person appointed to arrange for the disposition of remains who does not have a
registrant's identification number may obtain a copy of the file by calling
VADR's toll-free number to request a copy of the advance directive for a
specific registrant.
6.5 Providers
may access documents submitted to the registry by:
6.5.1 Becoming an authorized provider by
submitting a completed Provider Access Application and Provider Access
Agreement to VADR do the Department of Health. Once the application is
approved, VADR will issue a provider identification number and access code.
These documents are available on the Department's website;
6.5.2 Using the registrant's identification
number, or calling VADR's toll- free number to request a copy of a registrant's
document.
6.6 Whenever a
VADR file is accessed, VADR shall maintain a record by name of registrant, date
and identification number of the person or organization that accessed the
registrant's file.
6.7 Providers
who are issued a registry account shall agree to protect the identification
number issued to the provider and to limit access to the identification number
to their employees with a need to access the registry.
6.8 Providers who are issued a registry
account shall train their employees on the proper use of the registry and the
registrants' documents, and the obligation to report any unauthorized access or
misuse of information to the Department.
Section 7.0 Authority and Obligations of Health Care Providers, Health Care Facilities, Residential Care Facilities and Health Insurers
A health care provider, health care facility, or residential care facility which, in the course of providing treatment, checks the registry and finds a Provider Notification document or an Agent/Guardian Notification document without an amended Advance Directive shall make reasonable efforts to determine the wishes of the registrant. Consistent with 18 V.S.A. § 9713, the provider or facility shall not be subject to criminal or civil liability for providing or withholding health care or services in good faith pursuant to the Advance Directive on file with the registry.
7.1 Every hospital shall
designate an adequate number of individuals to explain the nature and effect of
an advance directive to patients as required by
18
V.S.A. §
9709(d).
7.2 No health care provider, health care
facility, residential care facility or health insurer shall discriminate in
rates or offering services or insurance on the basis of a person's advance
directive or DNR order in violation of
18
V.S.A. §
9709(e).
Section 8.0 Clinician Orders for Life Sustaining Treatment (COLST)
8.1 COLST
orders shall be issued on the Vermont DNR/COLST form. Health care facilities
and residential care facilities may document COLST orders in the patient's
medical record in a facility-specific manner when the patient is in their care.
(
18
V.S.A. §
9708 ).
8.2 A COLST order shall:
8.2.1. Be signed by the patient's clinician;
and
8.2.2 Be issued on the
Department's form pursuant to
18
V.S.A. §
9708(b);
and
8.2.3 Until January 1, 2018,
include the name of the patient, agent, guardian, in accordance with
14 V.S.A. §
3075(g); or other individual
giving informed consent for the COLST and the individual's relationship to the
patient; and
8.2.4 As of January 1,
2018, include the name of the patient, agent, guardian, in accordance with
14 V.S.A. §
3075(g); or surrogate giving
informed consent for the COLST and the individual's relationship to the
patient.
Section 9.0 Do Not Resuscitate (DNR) Facility Protocols and Orders
9.1 Every health care facility and
residential care facility must adopt a DNR protocol ensuring that DNR orders
are issued, revoked, and handled according to the same standards and process
for each patient at the facility. A copy of the facility's DNR protocol shall
be made available to anyone upon request.
9.2 DNR orders shall be issued on the Vermont
DNR/COLST form. Healthcare facilities and residential care facilities may
document DNR orders in the patient's medical record in a facility-specific
manner when the patient is in their care. (
18
V.S.A §
9708 ).
9.3 A DNR order shall:
9.3.1 Be signed by the patient's
clinician.
9.3.2 Certify that the
clinician has consulted, or made an effort to consult, with the patient and the
patient's agent, or guardian;
9.3.3
Unless based on medical futility, until January 1, 2018, include the name of
the patient. agent, guardian, or other individual giving informed consent for
the DNR order and their relationship to the patient;
9.3.4 Unless based on medical futility, as of
January 1, 2018, include the name of the patient, agent, guardian, or surrogate
giving informed consent for the DNR order and their relationship to the
patient; and
9.3.5 If the patient
is in a health care facility, or residential care facility, certify that the
requirements of the health care facility's DNR protocol have been
met.
9.4 A DNR order
based on medical futility shall also:
9.4.1
Certify that resuscitation would not prevent the imminent death of the patient
should the patient experienc e cardiopulmonary arrest; and
9.4.2 Be signed and certified by a second
clinician.
9.5 All
health care providers, including emergency medical personnel and staff of
health care facilities shall honor a DNR order unless the provider or facility
believe in good faith, after consultation with the agent or guardian where
possible and appropriate, that:
9.5.1 The
patient is not the person identified in the DNR order; or
9.5.2 The patient wishes to have the DNR
order revoked.
9.6
Whenever a DNR order is not honored for one of the reasons contained in Section
9.5, the health care provider or staff member shall document the basis for that
decision in the patient's medical record.
9.7 The most recently dated and signed
version of a DNR is the most current one that shall be honored by
professionals, regardless of how long ago it was signed.
9.8 A patient may suspend or revoke a DNR
order at any time by informing the clinician, destroying the written DNR/COLST
form, or acting in any way which evidences a specific intent to suspend or
revoke the DNR/COLST order unless the order is based on medical
futility.
Section 10.0 DNR Identification
Upon signing a DNR order, the clinician shall maintain a copy of the completed order in the patient's medical record and provide the original signed order with instructions to the patient, agent, or guardian unless the patient permanently resides within the issuing facility: If the patient for any reason leaves the issuing facility, or requests an original order, the issuing facility shall provide the patient with the original signed order. The presence of a signed DNR order on the Vermont DNR/COLST form shall be honored by all health care providers. A clinician who issues a DNR order on the DNR/COLST form shall authorize the issuance of a DNR Identification to the patient. A DNR identification shall be a necklace, bracelet, or anklet.
10.1 DNR identification issued after the
completion of a DNR order may be worn or possessed by the patient and shall
include the following minimum requirements:
10.1.1 The principal's name, date of birth
and gender;
10.1.2 One of the
following: "Vermont DNR", or "VT DNR", or "VT Do Not Resuscitate", or "Vermont
Do Not Resuscitate";
10.1.3 The
words "order on file" and a 24-hour, seven-day a week telephone number that is
toll free for the calling party to access information regarding the patient's
medical order;
10.1.4 An
individual-specific identification number to be used to identify the patient's
medical information on file; and
10.1.5 Any additional information requested
by the patient.
10.2 The
presence of a valid DNR Identification that meets the minimum requirements
shall be honored by all providers, including Emergency Medical Service
providers, the same as a signed, written DNR/ COLST order.
10.3 A DNR Identification that does not
conform with the requirements outlined herein shall not be recognized as a
valid DNR Identification and shall not be honored by providers.
10.4 Approved Vendors for DNR Identification
10.4.1 The Department shall maintain and post
on its website a list of approved vendors who can meet the minimum requirements
for DNR Identification set out in Section 10.1 and posted on the Department
website. Only venders who require a copy of a DNR order prior to issuing an
identification will be approved.
10.4.2 A copy of the signed DNR order must be
provided to the approved vendor prior to the issuance of a DNR ID to the
patient.
10.4.3 All vendors issuing
Vermont DNR identifications shall maintain copies of each individual DNR order
on file, which can be located via a specific individual identification
number.
10.4.4 Approved vendors
shall provide 24-hour seven-day a week toll free telephone access in the event
that information pertaining to a patient's medical order is needed.
10.5 Information about obtaining
financial assistance for purchasing and registering with a vendor to obtain a
Vermont DNR Identification as described in Section 10.1 of this rule will be
available on the Department's website.
Section 11.0 Experimental Treatments
11.1 A principal may authorize their
participation in treatment studies or drug trials, or may authorize their agent
to consent to treatment studies or drug trials, as part of health care provided
pursuant to an advance directive as defined in
18 VSA §
9701(1). Such studies or
trials must be conducted in compliance with 21 C.F.R. Part 56,21 C.F.R. Part
312, and any other applicable state or federal law. Experimental treatments
cannot be authorized by using the Ulysses Clause as provided by
18
V.S.A. §
9707(h).
STATUTORY AUTHORITY:
18 V.S.A. §§ 9708, 9719
Disclaimer: These regulations may not be the most recent version. Vermont may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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