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DO NOT RESUSCITATE (DNR) & PHYSICIAN ORDERS FOR LIFE-SUSTAINING TREATMENT (POLST)

A Do Not Resuscitate (DNR) Form (actual title: “Emergency Medical Services Pre-Hospital Do Not Resuscitate (DNR) Form) is an official State document developed by the California EMS Authority and the California Medical Association which, when completed correctly, allows a patient with a life threatening illness or injury to forgo specific resuscitative measures that may keep them alive. These measures include: chest compressions (CPR), assisted ventilation (breathing), endotracheal intubation, defibrillation, and cardiotonic drugs (drugs which stimulate the heart). The form does not affect the provision of other emergency medical care, including treatment for pain (also known as “comfort measures”), difficulty breathing, major bleeding, or other medical conditions. Many patients make their DNR wishes officially known because they do not want to be placed on life-assisting equipment in the event that their heart or breathing ceases.

  • DNR Form (PDF)
  • Physician Orders for Life-Sustaining Treatment (POLST) form  [PDF]

  • Physician Orders for Life-Sustaining Treatment (POLST)  [PDF] effective October 1, 2014

  • EMSA #111: DNR Guidelines
  • EMSA #111: DNR Guidelines effective October 1, 2014

Frequently Asked Questions

  1. Are there State guidelines covering the use of the DNR Form?

    Yes, you may download the EMS Authority’s “Guidelines for EMS Personnel Regarding Do Not Resuscitate Directives” via our website at www.emsa.ca.gov (access Publications # 111). You may also wish to contact the local EMS agency for your county to obtain a copy of their local DNR policies, which will be based on the State Guidelines, but may have additional specifications.

  2. How can I ensure that the EMT or paramedic responding to my emergency needs will honor my DNR wish?

    The best way to ensure that your wishes are honored is to complete the official State Pre-Hospital DNR form and have it signed by your physician and readily accessible when EMS help arrives. If you are concerned about the form being available at all times, you would be well-advised to obtain and wear a DNR medallion engraved with your DNR requirements.

  3. How can I obtain a DNR form?

    You may go to the EMSA website and download a form in either Microsoft Word format or in Adobe PDF format. These wording on these forms are not to be modified in any way except to include the required information of patient name, date signed by patient, surrogate’s relationship to patient, physician date signed, physician printed name and physician phone number. The EMS Authority keeps a small supply of paper forms for individual requests. You may contact our website at www.emsa.ca.gov and leave a request to have a form mailed to you, or call us at (916) 322-4336.

  4. How can I obtain a DNR Medallion?

    There are currently two (2) California Approved Medallion Providers.  They are the only venders in California that are currently approved to produce Statewide approved pre-Hospital DNR medallions.  Their contact information is the following:

    www.medicalert.org
    1-888-633-4298
    MedicAlert Foundation
    2323 Colorado Avenue
    Turlock, CA 95382

    www.caringadvocates.org
    1-800-647-3223
    Caring Advocates
    2730 Argonauta St
    Carlsbad, CA 92009

    • MedicAlert Foundation
    • Caring Advocates
    •  
  5. What if the EMT cannot find the DNR form or evidence of a medallion? Will they withhold resuscitative measures if my family asks them to?

    No. EMS personnel are taught to proceed with CPR when needed, unless they are absolutely certain that a qualified DNR advance directive exists for that patient. If, after spending a reasonable (short) amount of time looking for the form or medallion, they do not see it, they will proceed with lifesaving measures.

  6. What if I change my mind? Can I reverse my DNR orders?

    Absolutely. Your DNR orders are in place for as long as you wish them to be; you need only to destroy them if you wish to stop them. You should also contact your doctor’s office and family if you do so.

  7. Can the State DNR form and/or medallion be used in a skilled nursing facility or hospice?

    Yes. We encourage the adoption of the form for use by such facilities; however, many facilities do not know of the form, or they have their own in place, which may not be recognizable to the EMT or paramedic. If you have any concerns about the ability of the responding EMS personnel to be able to follow your DNR wishes, you would be well advised to obtain and wear a medallion.

  8. What about other legal documents, such as a Durable Power of Attorney for Health Care (DPAHC?) or “living wills”. Are they acceptable in place of the Pre-Hospital DNR form?

    While such official documents are generally respected by EMS personnel (check with your attorney and with the local EMS agency in your county), it is important to keep in mind that most EMTs or paramedics do not have the legal training needed to interpret such documents, and more importantly, do not have the time to read a lengthy document and make a life-or-death decision on the scene. They have been taught to err on the side of the patient, if they are in doubt (in other words, to provide life support). If you are at all concerned about their ability to follow your DNR wishes, you will want to follow the advice given in the answer to question number three, above.  

  9. Is this form and the medallion used in other states?

    Each state has its own DNR policies and procedures and accompanying paperwork. Some states are more specific than California, some less. If you are traveling out of state, you may wish to contact that state’s EMS office or public health department to determine what you will need to do to ensure that your DNR wishes will be followed. There is a list of state EMS agencies to contact on the EMSA Website.

  10. What is a POLST form?

        The Physician's Order for Life Sustaining Treatment (POLST) form, which can be accessed here  [PDF] is approved by the Emergency Medical Services Authority and the Commission on EMS, and developed by the Coalition for Compassionate Care of California.  The form contains additional treatment options beyond Do Not Resuscitate, for patients admitted to hospitals and other healthcare facilities. 

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