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

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/

Document Name

MOLST (Medical orders for life sustaining treatments) has taken the place of the Comfort Care/Do Not Resuscitate Verification.  However, existing DNRs will be honored.

Where do you get the form

You can find it on the mass.gov site or you can get it from your physician.

Who signs the form

The form is signed by the physician, a nurse practitioner or a physician’s assistant and the patient.

Who can request the form

Any adult can complete a MOLST form.

Patient Identification

The Comfort Care/DNR verification is the only document that EMS personnel can use to verify a DNR order is valid.  If a person has a MOLST, the form itself can be used.

How do you obtain a DNR or MOLST bracelet

Your physician must order a DNR bracelet for you.  The MOLST application contains bracelet inserts that can be used in generic wrist bracelets.

Revoking a DNR or MOLST

An EMS/DNR Order or MOLST may be revoked at any time.  

Photocopy

Photocopies of the form or the bracelet inserts are considered authentic DNR or MOLST documents. Because EMTs are trained to look for a bright pink form in outpatient settings, it is highly recommended that a bright pink-colored DNR or MOLST form stays with the patient at all times.

State info link

http://www.mass.gov/eohhs/gov/departments/dph/programs/hcq/oems/comfort-care/

http://www.molst-ma.org/

Other links

http://www.vialoflife.com/

DNR Bracelet links

Your physician must order a DNR braclet on your behalf.

Special Notes

Order a Vial of Life decal for your front door. The decal informs Emergency Medical Services team a DNR or MOLST has been prepared and can be found in your refrigerator.

Document Name

Do Not Resuscitate Order

Where do you get the form

Physicians should have copies of the form.  You can also get a copy at most hospices or download one here:

http://michigan.gov/documents/mdch/Do_not_resuscitate.policy_298357_7.pdf

Who signs the form

A physician must sign the DNR.   However, people whose religion opposes medical treatment don’t need a doctor’s signature.

Who can request the form

It may be requested by any individual 18 years or over.

Patient Identification

EMS will act based uon the information contained in the DNR.

How do you obtain a DNR bracelet

Once you have your DNR form completed, you can call the Michigan Hospice and Palliative Care Organization at 800-536-6300 to request a bracelet.

Revoking a DNR

You can revoke a DNR by tearing up the DNR form and returning any DNR identification bracelets.

Photocopy

A photocopy is considered an authentic document.

State info link

http://michigan.gov/mdch/0,4612,7-132-2940_3183_4895-19875–,00.html

Other link

http://www.vialoflife.com

DNR Bracelet links

You must call the Michigan Hospice and Palliative Care Organization at 800-536-6300. 

Special Notes