- Document Name
- Emergency Medical Services Pre-Hospital Do Not Resuscitate (DNR) form
- Physician Orders for Life Sustaining Treatment (POLST) form
- Where do you get the forms
- You should get the DNR or POLST form from a medical professional or download it here: http://www.emsa.ca.gov/Forms
- Who is permitted to request a DNR or a POLST
A patient with a life threatening illness or injury can request a DNR or a POLST.
- Who signs the form
- The form is signed by the physician as well as the patient.
- Patient Identification
- There is no requirement for a patient to wear a DNR identification medallion. However, California does recognize the medallion as proof of the patient having a DNR order.
- How do you obtain a DNR medallion
- There are currently only two state approved providers who can produce the pre-hospital DNR medallions. They are:
- Medic Alert Foundation 888-633-4298 http://www.medicalert.org
- Caring Advocates 800-647-3223 http://www.caringadvocates.org
- You will have to submit a copy of the DNR prior to being allowed to purchase a medallion.
- Revoking a DNR or a POLST
- An order can be revoked at any time. Just destroy the paperwork and also notify your doctor’s office and family.
- Photocopy
- Photocopies of a completed DNR or POLST form are valid.
- State info link
- Other links
- http://www.vialoflife.com/
- Special Notes
- Order a Vial of Life decal for your front door. The decal informs Emergency Medical Services team a DNR has been prepared and can be found in your refrigerator.