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

http://www.emsa.ca.gov/Forms

 

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.

Document Name

Emergency Medical Services Prehospital Do Not Resuscitate Order

Where do you get the form

You can  get the form from your physician or other medical personnel.

Who signs the form

The form is signed by the physician and the patient.

Patient Identification

The form is a three-part form. Give a copy of the form to EMS personnel.

How do you obtain a DNR bracelet

If you decide to wear a DNR bracelet, ask your physician to order a Comfort One DNR bracelet for you. The cost is $20.

Revoking a DNR

If you change your mind, destroy the enrollment forms, the wallet card and, if appropriate, the DNR bracelet. Also, notify your physician in writing that you have changed your mind.  If you are unable to communicate yourself, a person with a durable power of attorney can revoke the DNR status.

State links

http://dhss.alaska.gov/dph/Emergency/Pages/ems/programs/comfort_one.aspx

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.

 

WHAT ARE YOUR END OF LIFE WISHES?

A living will is one directive you complete documenting your end of life choices. 

A Do Not Resuscitate (DNR) order is another kind of advance directive documenting your end of life choices.

Here are some common questions and answers about a DNR.

What is the purpose of a DNR?

Why do you need to complete a living will and a DNR?

What happens if the  paramedics do not know you have signed a DNR?

How do you create an out of hospital DNR?

Q.   What is the purpose of a DNR?

A.  A DNR is a request not to have cardiopulmonary resuscitation (CPR) if your heart stops or if you stop breathing.  Unless paramedics or other emergency staff is given other instructions, they will try to resuscitate any patient whose heart has stopped or who has stopped breathing.

FACT: The exact rules for obtaining a DNR and for proving its validity vary widely from state to state.

Once you complete a DNR, make sure your physician and others are aware of your wishes.  Give a copy of your DNR to your primary physician and request that this information is added to your medical records.  If you are in a hospital, make sure a copy of your DNR is included with your medical chart.  Keep a copy of the original DNR form in your estate planning files.

FACT: Generally, doctors and hospitals in all states respect DNR orders.

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Q. Why do you need to complete a living will and a DNR?

A. The directions in your living will are only followed when your doctor believes you are in a terminal state and will not recover from your illness or injury.  The directions in your DNR are effective the moment you sign them and do not require any type of medical condition to be present for the DNR to be effective.

Elderly people sometimes want a DNR if they suffer from chronic illnesses and are concerned that their quality of life will suffer if they require resuscitation.

Q. What happens if the paramedics do not know you have completed a DNR?

A. If the paramedics or other medical personnel cannot locate your DNR, they will make an effort to save your life.

You can help the paramedics make the right treatment choices in several ways:

· Participate in the Vial of Life program.  The Vial of Life program is a nationwide effort to assist emergency personnel administer proper medical treatment for you when you can’t speak for yourself. A Vial of Life sticker is placed on your door.  This sticker tells the paramedic to look for your DNR and other medical information in a vial placed in your refrigerator. Some people recommend storing the DNR in the freezer in a blue freezer bag, as paramedics are trained to look there for DNR documents.

· Some states authorize the use of identification bracelets or tags as a way for you to notify medical personnel that you have signed a DNR.  Although all states authorize the use of a DNR, some states require special paper be used when printing as a means of authentication.

A FAMILY STORY: No DNR Present.

Kathy’s 92-year old mother was at Kathy’s house watching TV when she suddenly said she could not breathe. Kathy called an ambulance.

As they prepared to take her mother to the hospital, Kathy explained to the paramedic that she and her mother had decided not to resuscitate if the situation was such that her quality of life could be impaired.

The paramedic asked to see the DNR form.  Kathy replied the form was at her mother’s house in another state. Kathy could not provide a copy of the DNR signed by her mother to the paramedic.

The paramedic said they were allowed to wait sixty seconds for someone to provide the DNR.  After that, they are required by law to administer all available life saving techniques.

Kathy now keeps a copy of the DNR in her freezer and in her purse.  Her mother wears a DNR bracelet.

 

Q. How do you complete a DNR?

A. Your physician must complete and sign a DNR on your behalf.  In some states, you must wear a DNR bracelet showing you have a DNR on file.    The DNR state rules identify the name of the form required in your state and other facts you need to create an effective DNR. 

Like all legal documents, you need to complete a DNR before you  have a heart attack or other medical condition that would appear to compromise your mental abilities.   Once your mental capacity has been substantially compromised, it is possible for a physician to determine that you lack sufficient mental capacity to provide informed medical consent.

If the physician considers your mental capacity is diminished, it will be too late for you to instruct the medical staff not to resuscitate you.  These orders must be made when you are healthy.

Document Name

Do Not Resuscitate Order

Where do you get the form

Ask your physician to create a DNR on your behalf.  If your physician does not have a form, there is a sample as part of the Georgia statute.  Go to: http://www.lexisnexis.com/hottopics/gacode/Default.asp and then look for Title 31. Health Chapter 39. O.C.G.A. 31-39-4.

Who signs the form

The physician will sign the form.

Who can request a DNR

Any patient who has a medical condition which can be expected to result in imminent death or for whom CPR would be medically futile because it might only restore cardiac and respiratory function for a brief period of time.  A legal representative can also request a DNR for a patient who is in a vegetative or other unconscious state.

Patient Identification

There is no requirement for a patient to wear a DNR identification bracelet but it is acceptalbe if the patient chooses to do so.  However, there are specific guidelines.  The bracelet must be similar to identification bracelets worn in hospitals and must provide the following information in boldface type: DO NOT RESUSCITATE ORDER.  Patient’s name: _____________; authorized person’s name and phone number, if applicable; patient’s physician’s printed name and phone number; date of order not to resuscitate.                                    

How do you obtain a DNR bracelet

For assistance with finding a vendor for bracelets or necklaces, contact the Office of Regulatory Services at (404) 657-4076.

Revoking a DNR

You, or your designated health care agent, can give different instructions at any time, either orally, or by notifying your physician in writing.

Photocopy

You can make a photocopy of the original DNR form.

State info link

http://aging.dhr.georgia.gov/sites/aging.dhs.georgia.gov/files/imported/DHR-DAS/DHR-DAS_Publications/ELAP-%20DNR-12.pdf

Other link

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.

Document Name:

Illinois Department of Public Health (IDPH) Uniform Do-Not_Resuscitate (DNR) Advance Directive

Where do you get the form

To obtain a copy of the IDPH Uniform DNR form, you may request one from your health-care professional or facility. Copies also are available on the Illinois Department of Public Health’s Web site located at http://www.idph.state.il.us/public/books/advin.htm or by calling 217-785-2080

Who signs the form

The form is signed by the physician, the patient, and one witness.

Who can request a DNR

     An adult or an emancipated minor who does not wish to have CPR attempted when his or her heart and/or breathing stops may have a DNR order.

Patient Identification

There is no requirement for a patient to wear a DNR identification bracelet. EMS will honor a DNR form signed by a physician, patient and one witness.

How do you obtain a DNR bracelet

The IDPH does not specify any specific company from which to purchase the bracelet.  You should ask your physician for a recommendation when meeting to discuss the DNR form.

Revoking a DNR

The DNR order can be revoked in a variety of ways, such as by writing “VOID” in large letters across the front of the form. If you revoke a DNR order, you also should tell your family members, as well as each health-care professional and provider that has received a copy of the order. You may then choose not to have a DNR order, or you may choose to complete a new DNR order reflecting any changes you wish.

Photocopy

Photocopies of a completed IDPH Uniform DNR are valid.

State info link

http://www.idph.state.il.us/public/books/advdir4.htm

State statute link:

http://www.ilga.gov/legislation/ilcs/documents/075500400K65.htm

Other links

DNR Bracelet links

Illinois does not recommend a specific vendor.  However, here’s one you might try:

Medic Alert Foundation International http://tinyurl.com/dk3yun

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.  http://www.vialoflife.com/