Do Not Resuscitate (DNR) - Contra Costa Health Services

Contra Costa
Emergency Medical Services
DO NOT RESUSCITATE (DNR) ORDERS AND
PHYSICIAN ORDERS FOR LIFE-SUSTAINING
TREATMENT (POLST) IN THE PREHOSPITAL
SETTING
POLICY #: 20
PAGE: 1 of 2
EFFECTIVE: 01/01/12
REVIEWED: 10/01/11
I. PURPOSE
This policy identifies situations approved for withholding resuscitative measures or the treatment of
patients with an advanced airway.
II. DEFINITIONS
Agent: An individual, eighteen years of age or older, designated in a power of attorney for health
care to make health care decisions for the patient, also known as “attorney-in-fact.”
Immediate Family: The spouse, domestic partner, adult child(ren) or adult sibling(s) of the patient.
Conservator: Court-appointed authority to make health care decisions for a patient.
Advanced Health Care Directive (AHCD): A written document that allows an individual to provide
health care instructions or designate an agent to make health care decisions for that person. AHCD is
the current legal format for a living will or Durable Power of Attorney for Health Care (DPAHC).
Standardized Patient-Designated Directives:
• Statewide Emergency Medical Services Authority (EMSA)/California Medical Association (CMA)
Prehospital DNR Form
• Physician Orders for Life Sustaining Treatment (POLST): A standardized, signed, designatedphysician
order that addresses a patient’s wishes about a specific set of medical issues related
to end-of-life care
• A standard DNR medallion/bracelet (e.g. Medi-Alert).
III. POLICY
DNR ORDERS HONORED BY PREHOSPITAL PERSONNEL
Prehospital personnel may honor the following types of DNR orders:
A. A California EMSA/CMA Prehospital DNR form.
B. A California EMSA POLST form where Section A – Do Not Attempt Resuscitation/DNR has
been chosen.
C. An Advanced Health Care Directive (living will or Durable Power of Attorney for Health Care)
presented by an agent of the patient empowered to make health care decisions for the patient.
D. A standard DNR medallion/bracelet (e.g. Medi-Alert)
E. A DNR order in the medical record of a licensed healthcare facility (e.g., acute care hospital,
skilled nursing facilities, hospices, intermediate care facilities) signed by a physician. (electronic
physician’s orders are considered signed and will be honored)
F. A verbal DNR order given by the patient’s physician who is present at the scene.
A patient (or patient’s surrogate) may verbally rescind the DNR order at any time.
IV. PROCEDURE
A. COMPLYING WITH AN HONORED DNR ORDER
If an approved DNR order is available:
1. Verify the identity of the patient
2. Perform no life saving measures
3. Cancel the responding ambulance

Contra Costa
Emergency Medical Services
POLICY #: 20
PAGE: 2 of 2
B. COMPLYING WITH A POLST FORM WHEN PATIENT IS NOT IN CARDIAC ARREST
DNR orders only apply to patients in cardiac arrest. A patient with a DNR order that is not in
cardiac arrest should be provided treatment as appropriate for their complaint unless a POLST
is in place that directs care differently.
1. Verify the identity of the patient
2. Review the POLST form - Section B
a. If “Full Treatment” is marked – patient receives full care.
b. If “Limited Additional Interventions” or “Comfort Measures Only” is marked – No
Advanced Airway should be done.
Section C – does not apply to Prehospital Setting
V. SPECIAL CONSIDERATIONS
A. An approved DNR order is presented, but on-scene relatives object to the order or the validity of
the order is in question:
1. Provide all appropriate care/resuscitation measures for the patient. Although a patient’s
instructions should remain paramount, resuscitation is to be done until the situation is
clarified.
B. A patient presents with advanced or terminal disease and an incomplete approved DNR order
(e.g. no signature) is presented or no order is presented and an immediate family member,
agent or conservator at the scene requests no resuscitation:
1. With complete agreement of family and providers on scene, resuscitative efforts may be
withheld.
2. Base contact is not necessary.
3. This option is present because some patients with advanced or terminal diseases do not
have DNR or POLST forms. Resuscitation should be initiated if there is any question of
the circumstances or any disagreement of family or providers on scene.
C. If CPR is initiated prior to the presentation of an approved DNR order, CPR may be discontinued
without base hospital contact.
D. If multiple forms are presented follow the order with the most current date.
NOTE: EMS personnel shall document all relevant information on a PCR for all patients. Approved
DNR orders/POLST forms (copies acceptable) shall be attached to PCRs if a patient is not
transported.