Out-of-Hospital/
Information provided by www.atthecloseofday.com
At the Close of Day: A Person-Centered Guidebook on End-of-Life Care
These documents
vary by state. In general, most states have some type of document that tells
This page serves
as an adjunct to the information in the book At the Close of Day by
Lance Davis, MD and Albert Keller, DMin, although it is free to all. Our staff
has researched each state’s policies on this matter to help you to manage the
dying process. The information contained is as complete and accurate as we are
able to generate, but the policies and personnel in each state change often, so
you should only view this information as a starting point. Theoretically, your
doctor would have these documents for your state, or at least have access to
them. However, the dying process is complicated and your doctor may be unaware
of certain requirements for appropriate end-of-life care, so we encourage you to
bring information such as this to any doctor visits.
If you travel
state to state and are involved in end-of-life care, contact the
It is imperative
to keep the Out-of-Hospital
Specific title of document:
“Do
Not Resuscitate Order”
How to obtain document: Forms must be
issued by the patient’s attending physician. Forms may also be obtained from the
Alabama Department of Public Health and given
to the physician to sign. The telephone number there is (334)
206-5300.
Means of identification: A DNR
identification bracelet must be worn by patient for
his or her DNR Order to be honored by
Informational links: Go to pages 6
and 7 of the following link for information about Alabama DNR Orders:
http://www.alabar.org/members/LPconsumerguide.pdf
Link to State
Special notes/
considerations: The DNR
bracelet must be issued and placed on the wrist by the physician or a
representative of the physician. Contact your physician or the
State EMS offices for further information.
Specific title of document:
“Do
Not Resuscitate Order”/ “Comfort One Program”
How to obtain document: In order for a
person to obtain a valid DNR Order in
Means of identification: Patients are
given an enrollment form and a wallet card to serve as proof of enrollment. An
optional Comfort One identification bracelet may
also be purchased. The bracelet must be ordered by a physician and is especially
helpful for those who frequently travel outside of the home.
Informational links: Informational
brochure for patients and families (This brochure includes phone numbers for
health care providers to order forms and bracelets): http://www.chems.alaska.gov/EMS/Assets/Comfort%20One/comfort1family.pdfComfort One
Frequently Asked Questions: http://www.chems.alaska.gov/EMS/Assets/Comfort%20One/comfort1_FAQ_7-03.pdf
Link to State
Special notes/ considerations:
Contact your
local
Specific title of document:
“Do
Not Resuscitate Order” (also known as the Pre-hospital Medical Care
Directive)
How to obtain document: Patients may
obtain the form from their physician or print it out from the following link:
http://www.hs.state.az.us/bems/forms-pdf/dnr-lrg.pdf The form must be printed on
Means of identification:
Informational links: Information on
DNR Orders and link to print the form in either wallet or letter size:
http://www.hs.state.az.us/bems/dnr.htm
Link to State
Special notes/ considerations:
Both the letter
and wallet size forms must be printed on
Specific title of document:
“Emergency
Medical Services/ Do Not Resuscitate Order”
How to obtain document: Forms may be
obtained from the patient’s attending physician. Inform your physician that he
or she may request these forms from the State EMS Office
by calling (501) 661-2262.
Means of identification:
Informational links:
Link to State
Special notes/ considerations:
Only the
ORIGINAL Order form is valid and will be honored by the
Specific title of document:
“Emergency
Medical Services Prehospital Do Not Resuscitate Order (DNR Order)”
How to obtain document: You may print
out the form at the link provided below under ‘Informational Links’. Be sure to
print all three copies provided. You may also contact
the State EMS Office to request the form.
Means of identification: Every patient
will be given one copy of the Order to show to
Informational Links:
Link to State
Special notes/ considerations:
If
you choose to print the form from the link above, print out all three copies.
The first will be given to the patient to show to
Specific title of document:
“CPR Advance
Directives”
How to obtain document: Patients must
obtain a Colorado CPR Advance Directive form from their attending physician. It
is a distinctive form printed on security paper.
Physicians may order the forms from Hospital Shared Services at (303)
455-1420.
Means of identification:
Informational Links:
Link to State
Special notes/ considerations:
Upon execution
of the form, patient will receive the original and one (pink) copy of the form.
The original is to be kept on hand by the patient
to be shown to
Specific title of document:
Information
pending.
How to obtain document:
Means of identification:
Informational
Links:
Link to State
Special notes/
considerations:
Specific title of document:
“Pre-hospital
Advanced Care Directives Form”
How to obtain document: PACD forms
available to patients through their attending physician. If your physician does
not have the forms on hand, direct him or her to request
them from the State EMS Office.
Means of identification:
Informational Links: See
notes.
Link to State
Special notes/ considerations:
We
were unable to find any online information regarding the PACD form. Please
contact your physician or the State EMS Office for more
information. We found the people at the EMS Office to be extremely helpful and
friendly.
Specific title of document:
“Do
Not Resuscitate Order (DNRO)”
How to obtain document: The Florida Do
Not Resuscitate Order (DNRO) can be printed from the following link:
http://www.doh.state.fl.us/workforce/ems1/Forms/Other/Form1896.pdf. It MUST be
printed on YELLOW stock, 8 ½ x
14, legal size paper.
Means of identification: At the bottom of
the DNRO form is a patient identification device that is meant to be detached
and laminated so that it can travel with the patient. It
can be attached to a key chain, clipped to the bed or clothing, kept in a
wallet, or worn on a chain around the neck. It is equally as valid as the DNRO
form, but does not have to be completed for the form itself to be valid. Florida
EMS personnel will honor the original form, this patient identification device,
or a photocopy of the form as long as it is on canary yellow paper.
Informational Links: Link to DNRO
questions and answers:
http://www.doh.state.fl.us/ems/Administration/DNRO.html
Link to State
Special notes/ considerations:
Specific title of document:
Information
pending.
How to obtain document:
Means of identification:
Informational
Links:
Link to State
Special notes/
considerations:
Specific title of document:
“Comfort Care
Only- Do Not Resuscitate Order (CCO-DNR ORDER)”
How to obtain document: This form must
be administered to the patient by his or her attending
physician.
Means of identification: Patients must
wear a CCO-DNR bracelet in order for his or her CCO-DNR Order to be considered
valid. This bracelet is to be ordered as soon
as the Order has been executed by the patient’s physician and must be placed on
the patient’s wrist immediately upon receipt.
Informational Links:
Link to State
Special notes/ considerations:
A copy of
the form will be kept by the physician in the patient’s file, and one will be
given to the patient to keep. A third copy will be given to
the patient so that he or she can order the CCO-DNR bracelet or necklace from a
supplier. The supplier will then send their copy of the form to the State EMS
Office to be filed. Contact your physician or the State EMS offices for further
information.
Specific title of document:
“comfort One/ Do
Not Resuscitate Order (DNR Order)”
How to obtain document: The
Means of identification: The patient must
carry either the ORIGINAL comfort One/DNR form or wear a comfort One
identification bracelet or necklace for
Informational Links: Informational
brochure about comfort One/ DNR: http://www.idahoems.org/DNR_Brochure.pdf
Link to State
Special notes/ considerations:
Comfort One
jewelry must be intact and worn on the patient to be honored by
Specific title of document:
“Do
Not Resuscitate Order”
How to obtain document: The Illinois
DNR Order form may be printed from http://www.idph.state.il.us/public/books/DNR.pdf.
Note that it
must be reproduced on
brightly colored
Means of identification:
Informational Links: http://village.homewood.il.us/fire/DNRreq.htm
Link to State
Special notes/ considerations:
Contact your
local
Specific title of document:
“Out of Hospital
Do Not Resuscitate Declaration and Order”
How to obtain document: The Indiana
Out of Hospital DNR Declaration may be printed from http://www.in.gov/sema/ems/apps/ohdnrdec.pdf
Means of identification:
Informational Links: Patient
Self-Determination Act Information Packet: http://www.dcmh.net/pip.pdf
Link to State
Special notes/ considerations:
It
is recommended that you store the document in the refrigerator with a magnet
that identifies that there is such an order. Ask your physician
about obtaining the magnet and a tube in which to place the form. Contact your
physician or the State EMS offices for further
information.
Specific title of document:
“Out of Hospital
Do Not Resuscitate Order”
How to obtain document: The Iowa
OOH-DNR Order form may be printed from http://www.idph.state.ia.us/ems/pdf/physician_dnr_order.pdf
Means of identification: Either the Iowa
OOH-DNR Order form or a uniform identifier worn by the patient that alerts
Informational Links: http://www.idph.state.ia.us/ems/dnr.asp
Link to State
Special notes/ considerations:
Contact your
physician or local
Specific title of document:
“Do
Not Resuscitate Directive”
How to obtain document: The Kansas DNR
Directive can be printed from: http://www.kansashealthethics.org/whitepapers/DNR%20FORM%20Rev%2002.DOC
Means of identification: Information
pending.
Informational Links: DNR Directive
instructions:http://www.kansashealthethics.org/whitepapers/130DNRInstructions0502.doc
Link to State
Special notes/ considerations:
In Kansas,
the terminology is slightly different from most other states. Here, a DNR Order refers to instruction by the
physician who is
responsible for the care of the patient while admitted to a licensed medical
care facility or adult care home. A Pre-Hospital DNR Directive is a signed, dated and
witnessed document that allows an adult to state in advance his/her decision
that if his/her heart stops beating, or breathing stops, no medical procedure
will be undertaken to restart the heart or breathing. Contact your physician or
the State EMS offices for further information.
Specific title of document:
“EMS Do Not
Resuscitate Order (EMS DNR Order)”
How to obtain document: The EMS DNR
form can be printed from the informational link below.
Means of identification: The Kentucky EMS
honors the ORIGINAL form or an EMS DNR bracelet. The EMS-DNR bracelet is made by
signing and cutting off the bottom
of the Order and inserting it in a hospital-style bracelet that is then worn on
the wrist or ankle of the patient.
Informational Links:
http://kbems.ky.gov/NR/rdonlyres/07746719-2A13-429B-BFE1-7F397A3A26F4/1501/DoNotResuscitateForm1.pdf
Link to State
Special notes/ considerations:
An EMS DNR
Order may be executed by any adult in
Specific title of document:
“Living Will
Declaration”
How to obtain document: The Louisiana
Declaration form may be printed from the following link: http://www.sec.state.la.us/pubs/Liv_Will_Dec_form-1.pdf
Means of identification: In order to
declare that you do not want to be resuscitated, you must register your
declaration with the Secretary of State. Instructions for doing this
are at the bottom of the Declaration. The cost for registration is $20.00. Upon
registration, you will be sent a laminated wallet card and
identification bracelet that will notify
Informational Links: Scroll down to
chapter 1299.58.3 on the following link: http://biotech.law.lsu.edu/la/consent/la_consent.htm
Scroll down to
the ‘Living Will Declarations’ heading: http://www.sec.state.la.us/pubs/pubs-index.htm
Link to State
Special notes/ considerations:
In
Specific title of document:
Information
pending.
How to obtain document:
Means of identification:
Informational Links:
Link to State
Special notes/ considerations:
Specific title of document:
“EMS Do Not
Resuscitate and Medical Care Order”
How to obtain document: You may print
out the form from the following link: http://www.miemss.umaryland.edu/DNRorder_form.pdf
Means of identification:
Informational Links: Go to the second
page of the Order for information and instructions: http://www.miemss.umaryland.edu/DNRorder_form.pdf
Link to State
Special notes/ considerations:
Consult with
your physician or call the EMS/DNR program office at (410) 706-4376 for more
information.
Specific title of document:
“Comfort Care/Do
Not Resuscitate Order Verification”
How to obtain document: Comfort Care
forms and bracelets are only available to physicians. If your physician does not
have any forms on hand, direct him or her to the
following link for ordering information: http://www.mass.gov/dph/oems/comfort/ccinstr.htm
Means of identification:
Informational Links: Link to Comfort
Care program informational page, including instructions to request the
Verification Form and bracelet: http://www.mass.gov/dph/oems/comfort/ccare.htmLink to
sample CC/DNR Verification Order Form: http://www.mass.gov/dph/oems/comfort/formsamp.pdf
Link to State
Special notes/ considerations:
Photocopies of
the form or bracelet insert are not considered to be valid. If it is necessary
for the Verification Form to be in more than one
place, be sure to request that more than one original be issued. Contact your
physician or the State EMS offices for further
information.
Specific title of document:
“Do
Not Resuscitate Order”
How to obtain document: The form can
be printed from http://www.michbar.org/elderlaw/dnr_phys.pdf
or obtained from your physician.
Means of identification:
Informational Links: http://www.med.umich.edu/1libr/aha/umlegal05.htm
Link to State
Special notes/ considerations:
Very little
information on the Michigan DNR Order is available online. Please contact your
physician or State EMS for more information.
Specific title of document:
“Do
Not Resuscitate Order”
How to obtain document: Speak with
your physician about obtaining a DNR Order.
Means of identification: See special
notes below.
Informational Links:
Link to State
Special notes/ considerations:
In
Minnesota, the issue of Do Not Resuscitate Orders is local and varies greatly.
Our research indicates that the Minnesota
Medical Association is currently in the process of developing a statewide DNR
policy and form.
The
Minnesota Palliative Care Partnership has issued a statement about end of life
care public policy in the state. Read this statement here: http://www.minnesotapartnership.org/cgi-bin/ems.cgi.
We
will make all attempts to update this information as developments occur. In the
meantime, please contact your physician or local
Specific title of document: “Do Not
Resuscitate Order”
How to obtain document: Please speak
with your physician about obtaining a DNR Order.
Means of identification: See special
notes.
Informational Links: None.
Link to State
Special notes/ considerations:
According to the
State EMS Office,
“This is a local
issue and therefore is
Specific title of document:
“Do
Not Resuscitate Request Form”
How to obtain document: Speak with
your physician about obtaining a DNR Request Form.
Means of identification:
Informational Links: http://www.kcmo.org/health/ems/mast/s3.01.pdf
Link to State
Special notes/ considerations:
We
were able to find very little information on the Missouri DNR Request Form and
policies. Please contact your physician or local or state
Specific title of document:
“Comfort One
Program”
How to obtain document: All forms of
Comfort One identification must be obtained from your health care provider. It
is recommended that you print out the order form on
the following link and give it to your physician to order forms and
bracelets.
http://www.mtha.org/pdf/neworderform.pdf
Means of identification:
Informational Links: Link to Comfort
One Program information: http://www.mtha.org/comfort.htm
Link to State
Special notes/ considerations:
Bracelets other
than Comfort One (like generic ‘Do Not Resuscitate’ jewelry) will be disregarded
in the state of
Specific title of document:
Information
pending.
How to obtain document:
Means of identification:
Informational
Links:
Link to State
Special notes/
considerations:
Specific title of document:
“EMS Do Not
Resuscitate Order (EMS-DNR Order)”
How to obtain document: The patient
and his or her physician must complete an application and submit the application
with a $5.00 application fee to the Bureau of Licensure and
Certification, Emergency Medial Services Section. The patient will then receive
an EMS-DNR document issued by the Nevada State Health Division and an EMS-DNR
wallet card to carry with them at all times. For more information or to request
an EMS-DNR application, contact Nevada State Emergency Medical Services at
775-687-3065.
Means of identification:
Informational Links: http://www.unr.edu/ncehp/NV%20EMSDNR.htm
Link to State
Special notes/ considerations:
Contact your
physician or the State EMS offices for further
information.
Specific title of document:
“Do
Not Resuscitate Order”
How to obtain document: You may obtain
the New Hampshire DNR Order paperwork and bracelet from your physician.
Encourage him or her to get these and more information
by contacting the NHACEP Office at (603) 224-1909. They will only provide forms
or bracelets to physicians, visiting nurse agencies and hospice agencies – not
to individuals.
Means of identification: Patients with a
DNR Order in
Informational Links: http://www.nhacep.org/DNR%20Bracelets.htm
Link to State
Special notes/ considerations:
Contact your
physician or the NHACEP Office for further information.
Specific title of document:
“Out of Hospital
DNR Order”
How to obtain document: A printable
version of the New Jersey DNR Order form is available on pages 13-14 of the
informational packet linked below.
Means of identification:
Informational Links: Link to
informational packet that includes the form, instructions for purchasing
optional DNR bracelet and additional resources:http://www.njha.com/ps/pdf/dnr.pdf
Link to State
Special notes/ considerations:
New
Jersey EMS personnel do recognize and honor photocopies of a patient’s DNR
Order. It is recommended that you keep photocopies
displayed prominently in the home, car and any other setting in which you may
travel so that they are readily accessible to
Specific title of document:
Information
pending.
How to obtain document:
Means of identification:
Informational
Links:
Link to State
Special notes/ considerations:
Specific title of document:
“Nonhospital
Order Not to Resuscitate”
How to obtain document: Forms are
available by contacting the New York State Department of Health at (607)
732-2354 or may be printed from the following link:
http://www.health.state.ny.us/nysdoh/ems/pdf/doh3474.pdf
Means of identification:
Informational Links: Questions and
Answers about Do Not Resuscitate Orders in
Link to State
Special notes/ considerations:
Contact your
physician or the State EMS offices for further
information.
Specific title of document:
“DHHS Do Not
Resuscitate Order”
How to obtain document: The DNR Order
form must be issued by a physician. Health care facilities may order the form
from the Office of Emergency Medical
Services. Print out a copy of the DNR Order request form from the following link
and give it to your physician in case he or she does not have the DNR Orders on
hand: http://facility-services.state.nc.us/EMS/dnrordfm.pdf
Means of identification:
Informational Links: Information
about North Carolina DNR Orders: http://www.brunsco.net/modules.php?name=Departments&sop=viewarticle&artid=65
Sample DHHS DNR
Order: http://facility-services.state.nc.us/newdnr.jpg
Link to State
Special notes/ considerations:
Only the
ORIGINAL yellow form is
considered valid. Contact your physician or the State EMS offices for further
information.
Specific title of document:
Information
pending.
How to obtain document:
Means of identification:
Informational
Links:
Link to State
Special notes/
considerations:
Specific title of document:
“Do
Not Resuscitate Comfort Care Order”
How to obtain document: You may print
out the DNR Comfort Care Order form, wallet card and bracelet insert from the
following link and take them to your physician:
http://www.odh.state.oh.us/Rules/Final/Chap62/FR62_04.htm
(Scroll down to the bottom to the links to forms.)
Means of identification:
Informational Links: http://www.odh.state.oh.us/Rules/Final/Chap62/FR62_LST.htm
Link to State
Special notes/ considerations:
Reproductions of
the DNR Comfort Care Order are permitted. Contact your physician or the State
EMS offices for further information.
Specific title of document:
“Do
Not Resuscitate Consent Form”
How to obtain document: The form may
be printed from the following link onto 8 ½ x 14” paper: http://www.okdhs.org/aging/Documents/97-20.pdf*Please note that
by downloading and then printing the Do-Not-Resuscitate
Consent Form onto white paper,
you are losing the advantage offered by the Department of Human Services (DHS)
printed form. The DHS form is on distinctive yellow paper which gives it a
logo and quick-identification quality. The Do-Not-Resuscitate
Consent Form may be ordered by
calling the DHS Warehouse toll-free at (877) 283-4113.
Means of identification:
Informational Links: Link to DNR
Guide: http://www.okdhs.org/aging/Documents/97-20A.pdf
Link to State
Special notes/ considerations:
The
DNR Consent form is most commonly seen on bright yellow paper, but it may be on
any color or size paper. It is recommended that
the DNR Consent Form be kept on the patient’s refrigerator or above his or her
bed. Contact your physician or the State EMS offices for further
information.
Specific title of document:
Information
pending.
How to obtain document:
Means of identification:
Informational Links:
Link to State
Special notes/
considerations:
Specific title of document:
“Out of Hospital
Do Not Resuscitate Order”
How to obtain document: Forms,
bracelets and necklaces must be obtained from a physician. If your physician
does not have these on hand, take him or her the order form from
the following link: http://www.dsf.health.state.pa.us/health/lib/health/dnr_orderform8.pdf
Means of identification:
Informational Links: Out of Hospital
DNR Questions and Answers:
http://www.dsf.health.state.pa.us/health/cwp/view.asp?a=170&q=236932
Link to State
Special notes/ considerations:
Contact your
physician or the State EMS offices for further
information.
Specific title of document:
“Comfort One
Certification Form”
How to obtain document: The Comfort
One Certification Form must be obtained through the patient’s attending
physician. Physicians may request the forms from the
Department of Health. The white copy is for the patient’s records, the yellow is
for the physician’s records, and the pink copy is to be mailed to the Department
of Health.
Means of identification: Physicians will
complete a Comfort One bracelet with the Certification Form and place the
bracelet on the patient’s wrist or ankle. This bracelet is
similar to a hospital identification band and must be worn by the patient,
intact and not tampered with. The patient must be wearing an intact
Comfort One bracelet for the Comfort One order to be
honored.
Informational Links: We could not
find any Comfort One information online. Contact the Department of Health for
more information.
Link to Department of Health
Office: http://www.health.state.ri.us
Special notes/ considerations:
Contact your
physician or the Department of Health offices for further
information.
Specific title of document:
“EMS Do Not
Resuscitate Order”
How to obtain document: The EMS DNR
Order form may obtained from your physician, the Department of Health and
Environmental Control or can be printed from the
following link: http://www.scdhec.net/hr/pdfs/ems/dnr3462.pdf
Means of identification:
Informational Links: http://www.scems.com/edassn/forms/dnr.pdf
Link to State
Special notes/ considerations:
Contact your
physician or the State EMS offices for further
information.
Specific title of document:
See
special notes.
How to obtain document: See special
notes.
Means of identification: See special
notes.
Informational Links: See special
notes.
Link to State
Special notes/ considerations:
(HTML version): http://legis.state.sd.us/sessions/2004/bills/HB1274enr.htm
We will make all
attempts to update this information as developments occur. Please contact your
physician or the State EMS Office for more information.
Specific title of document:
“State of
How to obtain document: The Tennessee
EMS-DNR Order form may be printed from the following link: http://www2.state.tn.us/health/Downloads/g4119041.pdf
Make sure to
print out both pages- they are both needed for the Order to be
valid.
Means of identification:
Informational Links: Please see page
2 of the EMS-DNR form linked above for directions.
Link to State
Special notes/ considerations:
Photocopies of
the Tennessee EMS-DNR are honored. Contact your physician or the State EMS
offices for further information.
Specific title of document:
“Out-of-Hospital
Do-Not-Resuscitate Order”
How to obtain document: The form may be
printed from the following link: http://www.tdh.state.tx.us/hcqs/ems/dnr.pdf.
Print the form
on the front of a piece of paper and the
instructions on the back of the same sheet.
Means of identification:
Informational Links: Information
about OOH DNR Orders in
Link to State
Special notes/ considerations:
When printing
the form out or making copies, be sure to print the form on the front of a piece
of paper and the instructions on the back of the same
sheet. Contact your physician or the State EMS offices for further
information.
Specific title of document:
“EMS Do Not
Resuscitate Directive”
How to obtain document: The EMS DNR
Directive form is not available to the general public. It must be obtained
through a physician, who may request the form from the
Utah Department of Health.
Means of identification: Upon execution
of the EMS/DNR Directive, an EMS/DNR bracelet will be placed on the patient by
the physician. Only the ORIGINAL form or
bracelet will be honored on site by
Informational Links:
Link to State
Special notes/ considerations:
The
Utah EMS/DNR form has the
Specific title of document:
“Do
Not Resuscitate Order”
How to obtain document: Please consult
with your physician for information on obtaining a DNR
Order.
Means of identification: See special
notes.
Informational Links: See special
notes.
Link to State EMS Office:
http://www.healthyvermonters.info/hp/ems/emshome.shtml
Special notes/ considerations:
The
state of Vermont currently has no statewide DNR protocol or form. This appears
to be changing after the Last Acts coalition
recently gave the state extremely low scores on their end-of-life care report
card. The following link is to an article about the state Attorney
General’s recent public hearings on end-of-life care: http://www.atg.state.vt.us/display.php?pubsec=4&curdoc=710.
We will make all attempts to update this information as developments occur. In
the meantime, please contact your physician or the State EMS Office for more
information.
Specific title of document:
“Durable Do Not
Resuscitate Order”
How to obtain document: Durable DNR
Order forms are not available directly to the patient. A form must be issued by
the patient’s physician. Physicians may request the
forms by faxing a letter on the health care facility’s letterhead to the
Department of Health at (804) 864-7580. The following link also has more
information for physicians about requesting Durable DNR Order forms: http://www.vdh.state.va.us/oems/Files_page/ddnr/DNRrequest.pdf
Means of identification:
Informational Links: Durable DNR
Order Questions and Answers: http://www.vdh.state.va.us/oems/Files_page/DDNR/DDNRQandA.pdf
Link to State
Special notes/ considerations:
For
more information on the Virginia Durable DNR program, call Ruth Robertson at
(804) 864-7635 or e-mail her at: Ruth.Robertson@vdh.virginia.gov
Specific title of document:
“Physician’s
Orders for Life Sustaining Treatment (POLST)”
How to obtain document: The POLST form
must be obtained from the patient’s physician. You may print out an order form
from the following link to give to your physician:
http://www.doh.wa.gov/hsqa/emtp/download/polst_order_form.pdf
Means of identification: Emergency
personnel will honor the ORIGINAL green POLST
form.
Informational Links: POLST fact
sheet: http://www.doh.wa.gov/hsqa/emtp/download/polst_facts.pdf
POLST resource list: http://www.doh.wa.gov/hsqa/emtp/download/polst_resource.pdf
Sample POLST form: http://www.doh.wa.gov/hsqa/emtp/download/polst_sample.pdf
Link to State
Special notes/ considerations:
The
POLST form includes resuscitation, feeding, antibiotics and medical
intervention. POLST has
replaced the state’s
Specific title of document:
“Do
Not Resuscitate- Comfort Care Order”
How to obtain document: Please contact
your physician or local
Means of identification:
Informational Links: http://fems.dc.gov/fems/frames.asp?doc=/fems/lib/fems/H2.pdf
Link to State
Special notes/ considerations:
Contact your
physician or local
Specific title of document:
“Do
Not Resuscitate Order”
How to obtain document: You may obtain
the DNR Order from your physician. If the office does not have the form on hand,
direct them to the following link to request forms
and informational brochures: http://www.hsc.wvu.edu/chel/wvi/Pages/PractitionerRequestForm.asp
Means of identification: The West
Virginia DNR Order is on orange card stock. The
top section of the form is to be completed and returned to the Office of
Informational Links:
Link to State
Special notes/
considerations: You may also
want to talk with your physician about obtaining the POST (Physician Orders for
Scope of Treatment) form in addition to the
DNR. POST states your preferences for CPR, antibiotics, feeding tubes and
intravenous fluids.
Specific title of document:
“Do
Not Resuscitate Order”
How to obtain document: The Wisconsin
Do Not Resuscitate Order form is not currently available online, but you can
request the form from the Department of Health and
Family Services at (608) 267-7147 or from your physician.
Means of identification: Although you
must obtain a DNR Order form, only a special DNR bracelet worn by the patient
will be honored by the
Informational Links: http://www.wisbar.org/bar/lifeplan/conguide/4.html
Link to State
Special notes/ considerations:
There are two
kinds of DNR bracelets used in
Specific title of document:
“Comfort One
Program application”
How to obtain document: You can get
the Comfort One application form from your physician. With your physician, fill
out the form and mail it with a $20.00 application fee
to the
Means of identification:
Informational Links: http://wdhfs.state.wy.us/ems/comfort1.htm
Link to State
Special notes/ considerations:
Please contact
your physician or the state
