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Home My WebLink Aboutdnr-emsaEMERGENCY MEDICAL SERVICES PREHOSPITAL DO NOT RESUSCITATE (DNR) FORM PURPOSE The Prehospital Do Not Resuscitate (DNR) Form has been developed by the California Emergency Medical Services Authority, in concert with the California Medical Association and emergency medical services (EMS) providers, for the purpose of instructing EMS personnel to forgo resuscitation attempts in the event of a patient's cardiopulmonary arrest. Resuscitative measures to be withheld include chest compressions, assisted ventilation, endotracheal intubation, defibrillation, and cardiotonic drugs. The form does not affect the provision of other emergency medical care, including palliative treatment for pain, dyspnea, major hemorrhage, or other medical conditions. APPLICABILITY This form was designed for use in prehospital settings -- e.g., in a patient's home, in a long-term care facility, during transport to or from a health care facility, and in other locations 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 properly completed Prehospital Do Not Resuscitate Form (or an approved wrist or neck medallion) from criminal prosecution, civil liability, discipline for unprofessional conduct, administrative sanction, or any other 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 would be inconsistent with a health care decision that the individual signing the request would have made on his or her own behalf under like circumstances. This form does not replace other DNR orders that may be required pursuant to a health care facility's own policies and procedures governing resuscitation attempts by facility personnel. Patients should be advised that their prehospital DNR instruction might not be honored in other states or jurisdictions. INSTRUCTIONS The Prehospital Do Not Resuscitate (DNR) Form must be signed by the patient or by an appropriate surrogate decision-maker if the patient is unable to make or communicate informed health care decisions. The surrogate should be the patient's legal representative (e.g., a Durable Power of Attorney for Health Care agent, a court-appointed conservator, a spouse or other family member) if one exists. The patient's physician must also sign the form, affirming that the patient/surrogate has given informed consent to the DNR instruction. The original of the form should be retained by the 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. A copy of the form should be retained by the signing physician and made part of the patient's permanent medical record. A copy of the form may be used by the patient to order an optional wrist or neck medallion inscribed with the words "DO NOT RESUSCITATE-EMS." The Medic Alert Foundation (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 enrollment form 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 If a decision is made to revoke the DNR instruction, the patient's physician should be notified immediately and all copies of the form should be destroyed, including any copies 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 EMERGENCY MEDICAL SERVICES PREHOSPITAL DO NOT RESUSCITATE (DNR) FORM Original is to be kept by patient Submit a copy to be kept in patient's permanent medical record If an authorized DNR medallion is desired, submit a copy of this form, with Medic Alert enrollment form, to Medic Alert Foundation, 2323 Colorado Avenue, Turlock, CA 95381. To obtain the Medic Alert enrollment form, call 1-800-432-5378 An Advance Request to Limit the Scope of Emergency Medical Care I, request limited emergency care as herein described. (Print patient's name and medical record number) 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 pre-hospital 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/Surrogate Signature Date _________________________________________________________________________________ Print Surrogate's name Relationship to Patient Surrogate’s phone number By signing this form, the surrogate 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 this form. I affirm that this patient/surrogate is making an informed decision and that this directive is the expressed wish of the patient/surrogate. A copy 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 California License number Telephone THIS FORM WILL NOT BE ACCEPTED IF IT HAS BEEN AMENDED OR ALTERED IN ANY WAY PREHOSPITAL DNR REQUEST FORM