- 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.