Healthcare DNH Form

Patient Contact & Demographics

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Insurance & Payer Information

Medical History (Relevant)

Directive: Do Not Hospitalize Order

I, the undersigned patient or authorized decision-maker, hereby issue the following order regarding transfer or admission to an acute care hospital. I understand this order is intended to guide clinical decision-making and speaks for my wishes when I am unable to communicate.

Directive selection (check one):

I direct that I NOT be transferred or admitted to an acute care hospital under any circumstances, including for diagnostic testing, unless hospital transfer is required to provide comfort-focused symptom relief that cannot be provided in the current setting.

I direct that I NOT be transferred or admitted to an acute care hospital except under these specified conditions:

Comfort and palliative care: I authorize medical and nursing measures to relieve pain and distress and to provide comfort, including oral, subcutaneous or topical medications, oxygen for comfort, wound care, and other interventions consistent with comfort-focused goals. This DNH order does not prohibit treatments necessary to provide comfort.

Effect on other orders: This DNH order addresses transfer and admission to an acute care hospital. It is independent of orders regarding cardiopulmonary resuscitation or other life-sustaining treatments. If I wish to limit or permit such treatments, separate orders or directives must be completed.

If capacity to make medical decisions is in question, I request that attending clinicians document their assessment of capacity and consult available surrogates or legal decision-makers before interpreting this order.

Discussion, Acknowledgment, and Revocation

I acknowledge that my choices have been discussed with me (or with my authorized decision-maker) including the anticipated benefits, burdens, and reasonably foreseeable consequences of refusing hospital transfer. I understand that refusal of hospitalization may involve the risk of disease progression or death that could otherwise be treated in an acute care setting.

I understand that I may revoke or modify this DNH order at any time by:

• Providing a written, signed revocation;
• Verbally informing a treating clinician or facility staff (to be documented in the medical record); or
• Executing a subsequent advance directive or order that rescinds or supersedes this document.

Privacy, Release Authorization & Notices

By signing below I authorize the release and exchange of medical information between treating clinicians and facilities as necessary to implement this DNH order and to coordinate care consistent with my wishes. I understand that information released will be limited to what is necessary to carry out this directive.

I understand that clinicians retain professional and legal obligations to provide care that is consistent with accepted clinical standards and applicable law. This order is not intended to require clinically inappropriate or non-beneficial care.

I have had the opportunity to ask questions and have received answers I understand.

HIPAA Acknowledgment: I acknowledge that I have been informed that my health information may be shared among clinicians and facilities as needed to implement this order.

Signature

By signing below I attest that I am the patient or the duly authorized decision-maker for the patient named above and that I have the legal authority to make health care decisions on the patient's behalf.