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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) Georgia

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.

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) Michigan

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

Do Not Resuscitate (DNR) New Jersey

Document Name: “Out of Hospital DNR Order”
Where do you get the form: You can get a copy of the DNR Order from a licensed physician. If you need to provide a form to your physician, click here: http://www.state.nj.us/health/ems/dnr_introduction.shtml
Who signs the form: The physician and the patient or patient surrogate.

Who can request the form

Any mentally competent adult patient can request it.

Patient Identification: New Jersey EMS will honor the DNR Order form or a DNR bracelet that is worn on the patient’s ankle or wrist, has an insert displaying the patient’s name, physician name and date of the DNR, and has never been cut or removed.
How do you obtain a DNR bracelet: Once the DNR form is signed, you can obtain a bracelet from your physician or any health care facility licensed by the state of New Jersey (hospitals, long term care facilities, nursing homes, hospice). Call 1-973-857-5552 for more information.
Revoking a DNR: A DNR order may be revoked by the patient by removing the bracelet, verbally requesting the DNR be revoked, or destroying the DNR form. The patient should report the revocation of the DNR to their physician.
Photocopy: A photocopy is recognized as an authentic DNR form.
State info link: http://www.state.nj.us/health/ems/dnr_introduction.shtml
Other links: http://www.vialoflife.com/
DNR Bracelet links: Once you complete the DNR form, you can order a DNR bracelet from any vendor. However, you will have to show proof that you have a valid DNR.
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.