Do Not Resuscitate Order (DNR)

For some medical conditions such as terminal cancer, end-stage renal disease, or severe pneumonia, life saving intervention is not warranted when patients stop breathing or when their hearts stop beating. A valid Do not Resuscitate Order (DNR) tells medical professionals not to perform cardiopulmonary resuscitation (CPR) on a patient. DNR orders prove to be beneficial in preventing unnecessary or unwanted treatment at the end of an individual's life. 

Competent, adult patients can request a DNR order themselves. Patient requests can be made orally to a physician, or in writing in the form of a living will or advance directive prior to becoming ill.

To be eligible for the EMS/DNR Directive, a declarant must be 18 years of age and suffering from a terminal condition as determined by their physician. If the patient meets this criteria and desires that no cardiopulmonary resuscitation be done should they arrest, their physician will give them documentation and a bracelet to identify them as an EMS/DNR declarant. This modification to the State of Utah Living Will Act does not eliminate the Living Will, Special Power of Attorney or the medical Treatment Plan options. It simply provides a quick and easy recognition of declarants for Emergency Medical Technicians and Paramedics who respond to help these patients. The EMS personnel need only see the Directive or the bracelet and confirm the identity of the patient to concur with their wishes of no resuscitation.

For more information contact:
The Bureau of Emergency Medical Services
288 North 1460 West
Salt Lake City, Utah 84114-2852
Telephone: (801) 538-6435
Fax: (801) 538-6808

EMS DNR Directive: Section 75-2-1105.5

Attending Physician Responsibility: The attending physician will have the responsibility to determine and diagnose a terminal condition and explain that condition to the patient, and/or family or legal proxy. The physician should explain the alternatives available through the Living Will including DNR. The physician will also have the responsibility to execute the physician determination on the appropriate EMS/DNR form, if the patient should chose this option. The physician should counsel the patient in all options available to the patient.

The physician will issue the form, making sure that the Physician determination section is filled out completely. The physician should not sign the form until the patient has filled out the patient section and signed the form. After the physician signs the form, witnesses must then date and sign the form as will.

The physician should make two copies of the form, give the original with the watermark to the patient or proxy, keep one copy for the patient's medical record, and mail or fax the other copy to the State Bureau of Emergency Medical Services at the address shown on the form.

The physician will attach the bracelet to the patient or present the bracelet to the proxy for placement on the patient. The physician will also inform the patient that the directive may be revoked by an oral statement by the patient; or by destruction of both the directive and bracelet/necklace. The directive can be revoked by the proxy in the same manner. It can also be revoked by the attending physician if he/she determines that the patient is no longer terminal.

Patient Responsibility: The patient must make an informed decision concerning resuscitation for cardiac or respiratory arrest due to their terminal condition. The patient will inform their family of their decision and the location of the EMS?DNR directive. They should make their family aware of the appropriate areas for the directive to be placed. The directive should be hung in an unobstructed view above the patient on the wall or in close proximity to the head of the bed. If the patient is mobile, it is highly recommended they were the approved bracelet/necklace that will be easily recognized by EMS personnel.

They should further inform their family, that the directive can be revoked by destroying both the written directive and the bracelet/necklace. Removal of the bracelet will be considered to be destroying it. This can be done by the patient or their proxy. They can also verbally state to the EMS personnel their desire to be resuscitated should they arrest.

Family Responsibility: The family should be aware of the EMS/DNR directive, its location and the revocation process. they should further realize that emergency medical services personnel will respond should they be called either by calling 9-1-1 or the local emergency number. But most importantly they should know and respect the wishes of the patient, regardless of their own personal feelings. The family should also make a decision as to whether or not they will want the patient to go to the hospital if they call the EMS personnel.

EMS Provider Responsibility: The EMS personnel will be responsible to provide proper assessment of the patient's status and the patient's personal needs through the completion of a primary and secondary assessment of the patient. Remember, that the directive only applies to cardiac and/or respiratory arrest in the patient as it is related to their terminal condition and only in those situations where the patient has an active and proper EMS/DNR directive in place, or when the have another aspect of the Living Will that meets all the criteria that has been established for that part of the Act.

The EMS personnel will determine the existence of the EMS/DNR directive as a part of the patient assessment. The EMS personnel may need to begin resuscitation efforts while they determine the status of the patient. Begin treatment of the patient including CPR if the directive has been revoked. Avoid confrontation with family. If the family demands care, provide palliative care while contacting medical control and provide them with the information pertinent to the situation.

Remember, if an EMS/DNR directive is valid, the EMS personnel should honor the patient's request by withholding CPR. If the EMS personnel have personal feelings concerning the Directive and are unwilling to honor the directive, they should allow someone else to assume responsibility for patient care. If the EMS personnel should have any questions, they should contact medical control.

EMS Responsibility: The Bureau will print and distribute the EMS/DNR directive form and bracelets/necklaces to the patient through their physician. The bracelet/necklace can be attached to the patient as a support to the directive. In addition, the EMS Bureau will maintain copies of all directives to track the patients and verify the Directives for completeness and accuracy.

The EMS Bureau will also provide training for all EMS training officers concerning the EMS/DNR rules, and training materials to assist in educating personnel. The EMS Bureau will be a resource center to provide information concerning the rules and implementation of the EMS/DNR directive, and assist in training all who will fill out the forms to assure that they are done accurately.

Emergency Department Physician Responsibilty (On-line Medical Control): The Emergency Department personnel need to understand the EMS/DNR directive, how it is to be honored. In addition, they will act as a support for the EMS personnel, intervene in the pre-hospital management of a patient and interface with the attending physician, if it becomes necessary.

Hospital Responsibility: Directive and/or its bracelet/necklace and attempt to ascertain the existence of any other advance directives and to treat the patient appropriately to the desires given in those directives.

Other Health Care Workers' Responsibilities: Nursing homes, adult homes, hospitals, home health care nurses, and hospice units should become educated concerning the EMS/DNR directive. They should be instructed regarding the placement and removal of the EMS/DNR directive and/or bracelet/necklace. They must understand the directive and the request of the patient, and honor those wishes and not attempt to change or void the directive. They should not attempt to force or coerce a patient into signing an EMS/DNR directive or any other advance directive.

They will also be required to give the directive to the patient should the patient leave their facility at any time after the directive has been written. The directive must be presented to the EMS personnel upon their arrival if they are called to assist or transport the patient. Any and all documentation of advance directives should be readily available to EMS personnel when they are called to the scene.

General Information: The EMS/DNR directive is a single page document printed on white bond paper, carrying the Great State of Utah watermark. It has a section entitled Attending Physician's Determination, and a section entitled Declaration, and an area for the signatures of witnesses. There is information on the back of the form to identify who can act as proxy for the patient and who may witness the signatures of the patient and proxy and the physician. There is also a section that will be filled out and placed in the bracelet/necklace that will be given to the patient. The original EMS/DNR Directive must be given to the patient and placed in an unobstructed view above the patient on the wall or in close proximity to the head of the bed (except in health care facilities where it will be placed in the front or the patient's medical record). EMS personnel must see either the EMS/DNR Directive or the bracelet/necklace to validate the Directive. One copy shall be kept by the physician in the patient's medical file and one copy shall be sent to the Bureau of Emergency Medical Services at the address shown on the form. Any other copies of the form should not be made without express consent of the patient or their proxy.

Remember only the original EMS/DNR directive will be honored.

(Information from University of Utah Department of Internal Medicine)