Fillable Printable Emergency Medical Services Prehospital Do Not Resuscitate (DNR) Form - California

Emergency Medical Services Prehospital Do Not Resuscitate (DNR) Form - California

CMA PUBLICATIONS 1(800) 882-1262 WWW.CMANET.ORG

EMERGENCY MEDICAL SERVICES

PREHOSPITAL DO NOT RESUSCITATE (DNR) FORM

PURPOSE

The Prehospital Do Not Resuscitate (DNR) Form has been developed by the California EmergencyMedical ServicesAuthority, in

concert with the California Medical Association and emergencymedical services (EMS) providers, for the purpose of instructing

EMS personnelregarding a patient’s decision to forego resuscitative measures in the eventof cardiopulmonaryarrest. Resuscitative

measures to be withheld include chest compressions, assisted ventilation, endotrachealintubation, defibrillation, and cardiotonic

drugs. Thisform does notaffect the provision of life sustaining measures such as artificialnutrition or hydration or the provision of

other emergency medical care, such as palliative treatment for pain, dyspnea, major hemorrhage, or other medical conditions.

APPLICABILITY

This form was designed for use in prehospital settings--i.e., in a patient's home, in a long-termcare facility, during transport toor

froma health care facility, and in otherlocations outside acute care hospitals. However, hospitals are encouraged to honor the form

when a patient is transported to an emergency room. California law protects any health care provider (including emergency response

personnel) who honors a properlycompleted request regarding resuscitative measures, including a PrehospitalDo Not Resuscitate

Form (or an approved wrist or neck medallion), from criminal prosecution, civilliability, discipline for unprofessional conduct,

administrative sanction, or anyother sanction, if the provider believes in good faith that the action or decision is consistent with the

law and the provider has no knowledge that the action or decision wouldbe inconsistentwith a health care decision that the

individual signing the request would have made on his or her own behalf under like circumstances. This formdoes not replace other

DNR orders that maybe required pursuant to a health care facility's own policies and procedures governing resuscitation attempts

by facility personnel. Patients should be advised that theirprehospitalDNR instruction may not be honored in other states or

jurisdictions.

INSTRUCTIONS

The Prehospital Do Not Resuscitate (DNR) Form mustbe signed bythe patientor bythe patient’s legallyrecognized health care

decisionmaker if the patientis unable to make or communicate informed health care decisions. The legallyrecognized health care

decisionmaker should be the patient’s legal representative, such as a health care agent as designated in a power of attorney for health

care, a court-appointed conservator, or a spouse or other familymember if one exists. The patient’s physician mustalso sign the

form, affirming that the patient/legally recognized health care decisionmaker has given informed consent to the DNR instruction.

The white copyof the formshould be retainedbythe patient. The completed form (or the approved wrist or neck medallion—see

below) must be readily available to EMS personnel in order for the DNR instruction to be honored. Resuscitation attempts may be

initiated until the form (or medallion) is presented and the identity of the patient is confirmed.

The goldenrod copy of the form should be retained by the physician and made part of the patient’s permanent medical record.

The pinkcopy of the form may be used by the patient to order an optionalwristor neck medallion inscribed with the words “DO

NOT RESUSCITATE-EMS.” The Medic Alert Foundation (1(888)755-1448, 2323 Colorado Avenue, Turlock, CA 95381) is an

EMS Authority-approved supplier of the medallions, which will be issued only upon receipt of a properly completed Prehospital Do

Not Resuscitate (DNR) Form(together with an enrollmentform and the appropriate fee). Although optional, use of a wrist or neck

medallion facilitates prompt identification of the patient, avoids the problem of lost or misplaced forms, and is strongly encouraged.

REVOCATION

In the absence of knowledgeto the contrary, a health care provider may presume that a request regarding resuscitative measures is

valid and unrevoked. Thus, ifa decision is made to revoke the DNR instruction, the patient’s physician should be notified

immediately and all copies of the formshould be destroyed, including anycopies on file with the Medic Alert Foundation or other

EMS Authority-approved supplier. Medallions and associated wallet cards should also be destroyed or returned to the supplier.

Questions about implementation of the Prehospital Do Not Resuscitate (DNR) Form should be directed to the local EMS agency.

CMA PUBLICATIONS 1(800) 882-1262 WWW.CMANET.ORG

EMERGENCY MEDICAL SERVICES

PREHOSPITAL DO NOT RESUSCITATE (DNR) FORM

An Advance Request to Limit the Scope of Emergency Medical Care

I, _________________________________________, request limited emergency care as herein described.

(print patient’s name)

I understand DNR means that if my heart stops beating or if I stop breathing, no medical procedure to restart

breathing or heart functioning will be instituted.

I understand this decision will not prevent me from obtaining other emergency medical care by prehospital

emergency medical care personnel and/or medical care directed by a physician prior to my death.

I understand I may revoke this directive at any time by destroying this form and removing any “DNR” medallions.

I give permission for this information to be given to the prehospital emergency care personnel, doctors, nurses or

other health personnel as necessary to implement this directive.

I hereby agree to the “Do Not Resuscitate” (DNR) order.

Patient/Legally Recognized Health Care Decisionmaker Signature Date

Legally Recognized Health Care Decisionmaker’s Relationship to Patient

By signing this form, the legally recognized health care decisionmaker acknowledges that this request to forego resuscitative measures is consistent with

the known desires of, and with the best interest of, the individual who is the subject of the form.

I affirm that this patient/legally recognized health care decisionmaker is making an informed decision and that this

directive isthe expressed wish of the patient/legally recognized health care decisionmaker. Acopy of this form is

in the patient’s permanent medical record.

In the event of cardiac or respiratory arrest, no chest compressions, assisted ventilations, intubation, defibrillation,

or cardiotonic medications are to be initiated.

Physician Signature Date

Print Name Telephone

THIS FORM WILL NOT BE ACCEPTED IF IT HAS BEEN AMENDED OR ALTERED IN ANY WAY

PREHOSPITAL DNR REQUEST FORM

White Copy:

To be kept by patient

Yellow

Copy:

To be kept in patient’s permanent medical record

Pink Copy:

If authorized DNR medallion desired, submit this form with Medic Alert enrollment form to: Medic Alert Foundation, Turlock, CA 95381