DNR and POLST Forms
For assistance with completing a DNR/POLST form, please partner with your doctor or contact the Coalition for Compassionate Care of California (CCCC) at (916) 489-2222.
Do Not Resuscitate (DNR)
The Prehospital Do Not Resuscitate (DNR) Form is an official State document developed by the California EMS Authority, in concert with the California Medical Association and emergency medical services (EMS) providers, for the purpose of instructing EMS personnel regarding a patient’s decision to forgo resuscitative measures in the event of cardiopulmonary arrest. Resuscitative measures to be withheld 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 life sustaining measure such as artificial nutrition or hydration or the provisions of other emergency medical care, including treatment for pain, difficulty breathing, major bleeding, or other medical conditions.
The DNR must be signed by the patient or by the patient’s legally recognized health care decision maker if the patient is unable to make or communicate informed health care decisions. The patient’s physician must also sign the form, affirming that the patient/legally recognized health care decision maker has given informed consent to the DNR instruction. The DNR form should be clearly posted or maintained near the patient.
To obtain a DNR form, please contact the California Medical Association (CMA) publications office directly, at 1(800) 882-1262 or visit the CMA store webpage to purchase the form.
Physician Orders for Life-Sustaining Treatment (POLST)
The Physician’s Order for Life Sustaining Treatment (POLST) form is approved by the Emergency Medical Services Authority (EMSA) and the Commission on EMS, and developed by the Coalition for Compassionate Care of California (CCCC). The POLST form is a medical order that gives seriously ill patients more control over their care by specifying the type of medical treatment a patient wishes to receive at the end of life. The EMSA approved POLST form must be signed and dated by a physician, or a nurse practitioner or a physician assistant acting under the supervision of the physician, and the patient or legally recognized health care decisionmaker. The POLST form should be clearly posted or maintained near the patient.
- Per CCCC, it is recommended that POLST be copied on bright pink paper to help ensure that the document stands out and is followed. However, POLST on any color paper is valid.
For additional information, visit the Coalition for Compassionate Care of California’s web site.
The most accurate form of identification for patients outside of licensed facilities is a medallion or bracelet worn by the patient. Currently approved Medallion Providers for the State of California include:
If you are interested in becoming an approved medallion provider for the State of California, please contact EMSA at (916) 322-4336.
Frequently Asked Questions
- Are there State guidelines covering the use of the DNR Form? Yes, you may download the EMS Authority’s EMS Personnel Guidelines, Publication # 311. You may also 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.
- 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 be sure the DNR or POLST form is clearly posted or maintained near the patient.
- Will the EMT withhold resuscitative measures at the families request if the EMT cannot find the DNR form or evidence of a medallion? NO. Unless they are absolutely certain that a qualified DNR advance directive exists for that patient EMS personnel will proceed with resuscitative measures.
- Can I reverse my DNR orders? Yes. 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.
- 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. The best way to ensure that your wishes are honored is to be sure the facility is aware of and provided a copy of the DNR or POLST form and that they are clearly posted or maintained near the patient.
- 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. If in doubt, the EMS personnel will err on the side of the patient and provide resuscitative measures.
- Is the California DNR/POLST and approved 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.
- Can I use the California DNR form outside of California? The California DNR form is made for the use within California. If you live outside of California, you need to check with your state of residence for their forms.