Free Do-Not-Resuscitate Guide

Prehospital DNR legislation often defines exactly what emergency treatment is to be withheld from individuals with valid DNR orders. Such things as CPR, defibrillation (electrical shock to heart), and intubation (insertion of a tube to assist in breathing) are typically not administered if there is a valid DNR order. However, measures that are necessary to alleviate pain or that will make an individual more comfortable are generally not withheld. This is important so that individuals with prehospital DNR orders can still receive "comfort care" from emergency responders. Your physician can explain the specific procedures that will or will not be withheld in your state.

Typically the administration of a prehospital DNR program involves a state's Emergency Medical Service ("EMS") department. Additionally, state medical or hospital associations may be involved. Common features of state programs include:

• Standard and Uniform Documents

• DNR Bracelets

• Physician Involvement

• Comfort Treatment Not Withheld

• Miscellaneous Provisions

Many states require or encourage individuals to wear an official bracelet (possibly similar to a hospital identification band) or a medallion that communicates their DNR status. Emergency responders are instructed to look for such bracelets before initiating emergency treatment. Some states require that individuals place the official DNR document in certain places in their home, such as at a bedside table or on the door of a bedroom. EMS responders are then instructed to search in those specific places for the document.

In hospitals and other health care facilities, a physician can write an "order" in an individual's medical record that authorizes other health care providers to withhold resuscitative measures such as CPR. Such orders are usually written after consultation with the patient and the patient's family. The order, sometimes referred to as a do-not-resuscitate (DNR) order, also may be based on an individual's documented wishes in a living will or other health care directive.

A "DNR order" authorizes the deviation from the standard protocol of resuscitating individuals who suffer a cardiac or respiratory arrest. A DNR order means that medical procedures will not be taken to restart an individual's heart or breathing.

Because an emergency responder would not have access to your medical record to determine if there is a DNR order, states have developed other methods to communicate DNR orders to emergency responders.

Emergency responders in the community, similar to physicians and nurses in a hospital, generally have a duty to provide emergency treatment such as CPR (cardiopulmonary resuscitation) when responding to an emergency. However, some individuals do not want to be resuscitated.

Over one-half of the states have passed legislation or regulations that provide a "prehospital DNR program" by which a physician's DNR order can be honored outside of the hospital setting. This program provides information on such programs.

If you need more information after consulting your physician, there are a variety of groups or organizations that may be helpful. Even if you are not a hospice patient, a local hospice staff member may be able to explain prehospital medical care, options available in your state to avoid prehospital resuscitation, or where else to look for information. A local hospital's pastoral care or chaplain department may also be helpful.

Additionally, state or local Emergency Medical Services (EMS) offices will likely have information. Many states that do not have an official prehospital DNR program have recently had pending legislation for such programs. Individuals at state EMS offices will likely be aware of pending legislation and can also explain the duties of emergency responders and possible options to avoid unwanted resuscitation.

It is very likely that, in response to specific questions about how you might actually avoid prehospital emergency treatment, individuals will direct you back to your physician. Unlike other individuals, your physician will understand your personal medical condition and thus can best explain the consequences of foregoing medical treatment. However, other professionals (such as nurses, social workers, counselors and chaplains) may be willing to provide general information to you or at least refer you to another source of information.

Similar to the hospital setting, physicians generally must authorize an individual's DNR status in the prehospital setting. Documents generally must be signed by an attending physician. In fact, many states only allow patients to obtain DNR documents through physicians. DNR forms without a physician's signature may not be honored in any state.

In general, states with official prehospital DNR programs provide that individuals may revoke the DNR order in any manner that effectively communicates the revocation. Physical destruction of the actual DNR document displayed in an individual's home or an indication on that document that it is revoked is frequently suggested. Additionally, if an individual wears a bracelet or medallion to communicate his or her DNR status, the bracelet or medallion should be removed if an individual desires to be resuscitated.

Individuals should also communicate with their physician about a desire to revoke a prehospital DNR order. Some states maintain a registry of individuals with DNR orders and thus it is important to follow your state's particular procedure to revoke DNR status.

Finally, an oral revocation by an individual is generally effective to revoke a prehospital DNR status. In other words, if conscious and able to communicate, an individual can simply tell emergency responders that he or she does want resuscitation and the emergency responders should disregard the DNR order.

1. The prehospital do-not-resuscitate (DNR) guide is not a legal document and does not require any signatures.

2. In general, it is always a good idea to discuss your desires and beliefs about medical treatment with your physician, family, and other individuals with whom you are particularly close. This increases the likelihood that your wishes will be honored in the future.

States typically provide a special form to document a prehospital DNR order. These documents may also function to communicate DNR status to emergency responders. DNR "forms" or "orders" are usually standardized and may even be officially issued by a state agency. Some states require forms to be a certain color (for example, orange), on special paper, or have a state seal. EMS responders may be required to resuscitate an individual if a DNR document does not comply with the official format or if there is any doubt about the validity of a DNR order. Additionally, responders in one state may not be authorized to honor a DNR document from another state.

The standardization of DNR documents reduces the possibility that a document could be tampered with or falsely prepared by individuals with less than a full understanding of its consequences. Additionally, an emergency responder can quickly identify a document and verify its authenticity by comparing it to an officially approved form.

Because of the common requirement for standardized and official DNR documents, this program does not provide the opportunity to create a prehospital DNR document. It is important that you comply strictly with all state requirements to have a valid prehospital DNR order.

The following states have statutes or regulations that authorize the use of prehospital DNR documents. Other states may have protocols and unofficial programs. States have used a variety of phrases to describe the order, form, or document. Additionally, many states use more than one phrase to describe their programs or documents. The following is a partial list of each state's terminology.

Alabama -- Prehospital Do Not Resuscitate Order
Alaska -- Do Not Resuscitate Order
Arizona -- Prehospital Medical Care Directive
Arkansas -- Do Not Resuscitate Order
California -- Prehospital DNR Request Form or Prehospital Do Not Resuscitate Form
Colorado -- Cardiopulmonary (CPR) Directive
Connecticut -- Do Not Resuscitate (DNR) Order
Florida -- Prehospital Do Not Resuscitate Order (DNRO)
Georgia -- Do Not Resuscitate Order
Hawaii -- Comfort Care Only Document
Idaho -- Do Not Resuscitate (DNR) Order or Identification
Illinois -- Do Not Resuscitate Order
Indiana -- Do Not Resuscitate Declaration and Order
Iowa -- Out-of-Hospital Do-Not-Resuscitate Order
Kansas -- Do Not Resuscitate Order or Directive
Kentucky -- Standard Form or Identification Regarding Wish Not To Be Resuscitated
Louisiana -- Do-Not-Resuscitate Identification Bracelet
Maine -- EMS Comfort Care / DNR Program or Do Not Resuscitate (DNR) Order
Maryland -- Do Not Resuscitate Order
Massachusetts -- Comfort Care / Do Not Resuscitate Order ("DNR") Order Verification
Michigan -- Do Not Resuscitate Order or Identification Bracelet
Missouri -- Do Not Resuscitate (DNR) Request
Montana -- Do Not Resuscitate Order or Identification
New Hampshire -- Do Not Resuscitate Order
New Mexico -- EMS Do Not Resuscitate (DNR) Order or EMS DNR Order
New York -- Nonhospital Order Not to Resuscitate (DNR Order)
Nevada -- Do-Not-Resuscitate Identification or Order
North Carolina -- Portable Do Not Resuscitate Order
Ohio -- Do-Not-Resuscitate Order or DNR Identification
Oklahoma -- Do-Not-Resuscitate Identification or Consent Form
Oregon -- POLST or Physician Order for Life Sustaining Treatment
Rhode Island -- "Comfort One" or DNR Bracelet
South Carolina -- Do Not Resuscitate Order
Tennessee -- Do Not Resuscitate Order
Texas -- Out-of-Hospital Do-Not-Resuscitate (DNR) Order
Utah -- EMS/DNR Form, Directive, or Declaration
Virginia -- EMS Do Not Resuscitate Order
Washington -- EMS - No CPR Form (Directive)
West Virginia -- Do Not Resuscitate Order
Wisconsin -- Do Not Resuscitate Order or Bracelet
Wyoming -- Cardiopulmonary Resuscitation Directive or "Comfort One"

In many circumstances, individuals who need emergency treatment, including the administration of CPR, will make a full recovery and not suffer any serious adverse effects from the condition necessitating emergency treatment or the treatment itself.

For example, an individual may make a complete recovery after emergency treatment for conditions such as allergic reactions, electrical shock, choking on food at a meal, and even a cardiac arrest as a result of a heart attack. Even individuals who have been diagnosed with a terminal illness may completely recover from another short-term medical condition from which they are resuscitated. It is, therefore, often quite appropriate for individuals with significant health problems to receive emergency treatment.

The decision to forego emergency treatment is a very personal one. Personal and spiritual beliefs, family circumstances, and an individual's current and future expected medical condition are all important factors in decisions about medical care.

One of the best things to do to learn more about prehospital DNR programs is discuss the issue with your physician. Your physician should be able to explain the potential consequences of foregoing resuscitation in your specific circumstances and give you some guidance on how to avoid unwanted treatment.

It is also important to tell your family about your wishes. Additionally, completion of a Living Will, Health Care Power of Attorney, or Advance Health Care Directive are good ways to document your wishes about medical care. Such documents are generally not substitutes for a prehospital DNR order but allow you to document your wishes for circumstances other than prehospital medical care.

Many states provide that emergency care will be provided to individuals even though they have a valid prehospital DNR order under certain circumstances, including natural disaster, trauma, mass casualties, or attempted suicide.

Additionally, some states specifically state that the order is not effective if it is known that an individual is pregnant.