Tag Archives: DNR Order

Do Not Resuscitate (DNR) & POLST California

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.

Do Not Resuscitate (DNR) Illinois

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/

Do Not Resuscitate (DNR) Massachusetts – has transitioned to MOLST

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.

Do Not Resuscitate (DNR) New York (& it’s alternative – MOLST)

Document Name: “Out of Hospital DNR” or Medical Order for Life-Sustaining Treatment (MOLST)
Where do you get the form: Any licensed physician should have a blank DNR Order or a MOLST form. If you need to provide a form to your physician, you can get one from the NY state website. You can find the links below.

Who is permitted to request a DNR order for themselves

All adult patients can request a DNR order.

Who signs the form

The physician and the patient consent to a DNR order in writing. However, only the physician actually signs the DNR form. Both the physician and the patient sign the MOLST form.

Patient Identification: New York EMS will honor the DNR Order form, a standard DNR bracelet or a properly executed MOLST form.
How do you obtain a DNR bracelet: New York state has not approved a specific vendor. They suggest that once the DNR form is signed, you can obtain a bracelet from Medic Alert. Since the only specific requirements are that it is a standard metal bracelet which includes a caduceus and the words “DO Not Resuscitate”, you can probably find the bracelet at other companies as well.
Revoking a DNR or a MOLST: You, or anyone who consents to a DNR or MOLST order on your behalf, can remove the order by telling doctors, nurses or others about the decision. This need not be done in writing. Once informed of your wishes, your physician must record the revocation in your chart, cancel the order and make diligent efforts to retrieve all copies of your executed form, as well as your DNR bracelet if applicable.
Photocopy: An original DNR form is printed in black ink on white paper. A MOLST form is usually printed on bright pink paper. A photocopy of either is recognized as an authentic DNR form.
State info link: http://www.health.ny.gov/professionals/ems/policy/99-10.htm

Other link
http://tinyurl.com/djekqu
http://www.health.ny.gov/forms/doh-5003.pdf
DNR Bracelet links: DNR bracelets may be obtained from most companies that sell medical identification bracelets, provided they have a copy of your New York DNR form (DOH-3474) on file. Here’s one bracelet source you can check:

Medic Alert Foundation International, Attn DNR, 2323 Colorado Avenue, Turlock, CA 95382 Phone: 1-888-633-4298, 3, 1 or ask for DNR. http://www.medicalert.org/product/catalog/medical-ids

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.

Do Not Resuscitate (DNR) Ohio

Document Name:: Ohio has two versions of the DNR – “Do Not Resuscitate Comfort Care Order ” AND ” Do Not Resuscitate Comfort Care Order-Arrest Order”. The difference relates to the amount and timing of care given. Ask your medical professional for an explanation.

Where do you get the form

A physician, a certified nurse practitioner or a clinical nurse specialist can provide the form or you can get it here: http://www.odh.ohio.gov/pdf/forms/dnrfrm.pdf
Who signs the form: The physician, certified nurse practitioner or clinical nurse specialist and the patient sign the DNR order.

Who can request a DNR

Any adult can request one.

Patient Identification: A wallet card, an EMR hospital bracelet or the completed form can be used by EMS personnel.
How do you obtain a DNR bracelet: The state of Ohio does not endorse a specific vendor but supplies a list of suggestions on their site.
Revoking a DNR: You may revoke the DNR at any time, either orally or in writing. You may also revoke the DNR by destroying the DNR form, wallet card or DNR bracelet.
Photocopy: A photocopy is recognized as an authentic DNR form.
State info link:: http://codes.ohio.gov/orc/2133.02; http://codes.ohio.gov/orc/2133.21
Other links:: http://www.vialoflife.com/
DNR Bracelet links: DNR bracelets may be obtained from most companies that sell medical identification bracelets, provided they have a copy of your Ohio DNR form on file. Here is a link to the list on the Ohio state website: http://www.odh.ohio.gov/~/media/ODH/ASSETS/Files/dspc/health%20care%20service/jewerlyresourcelist6/08.ashx
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.Ohio has two types of DNR forms. In addition, your Living Will may include some DNR language. Discuss these options with your physician or attorney and select the one appropriate for your intentions.