Medical Directive - DNR

ALASKA DNR / POLST REQUEST AND CLINICAL WORKSHEET

Not a DNR Order, DNR Identification, or POLST Form

CRITICAL NOTICE: Signing this worksheet does not create an Alaska DNR order and does not direct EMS or another provider to withhold cardiopulmonary resuscitation. Under AS 13.52.065, the operative order must be issued by a physician, advanced practice registered nurse, or physician assistant. Use the current department-approved DNR or Alaska POLST materials supplied through the treating clinician.

This worksheet collects information for a goals-of-care discussion and for the clinician who will decide whether to issue a separate Alaska-compliant medical order.

1. PATIENT INFORMATION

2. REQUEST FOR A CLINICAL DISCUSSION

I request a discussion with my Alaska physician, advanced practice registered nurse, or physician assistant about whether I qualify for, and should receive, a DNR order or Alaska POLST medical order.

My current goals and preferences are:

☐ If I have no pulse or am not breathing, I do not want CPR attempted if an authorized clinician issues a valid order for me.

☐ I want comfort-focused treatment and symptom relief discussed separately from CPR status.

☐ I want the following questions, values, or treatment preferences discussed:

[____________________________________________________________]

[____________________________________________________________]

I understand that this request is not itself a medical order and that care, including CPR, may begin while providers confirm my identity and DNR status under the Alaska protocol.

Patient signature: [________________________________] Date: [__/__/____]

If the patient is under 18, parent or guardian name: [________________________________]

Relationship or authority: [________________________________]

Signature: [________________________________] Date: [__/__/____]

AS 13.52.065(a) requires the patient's consent, or the consent of a parent or guardian when the patient is under 18. A signature on this worksheet documents a request for review only; it does not substitute for the clinician-issued order.

3. CLINICAL REVIEW — COMPLETE BY AUTHORIZED ALASKA CLINICIAN

Clinician name: [________________________________]

Profession: ☐ Physician ☐ Advanced practice registered nurse ☐ Physician assistant

Alaska license number: [________________________________]

Date of clinical review: [__/__/____]

3.1 Eligibility and consent

Under AS 13.52.390, a DNR order is a directive from a licensed physician, advanced practice registered nurse, or physician assistant to withhold emergency CPR from a “qualified patient.” A qualified patient has a qualifying condition: a terminal condition or permanent unconsciousness.

☐ I confirmed the patient's identity.

☐ I evaluated whether the patient is a qualified patient under AS 13.52.390(33)-(34).

☐ I obtained the consent required by AS 13.52.065(a).

☐ I discussed what the proposed order would and would not address, reasonable alternatives, and the patient's goals.

Qualifying condition and clinical findings:

[____________________________________________________________]

[____________________________________________________________]

3.2 Medical-record requirement and disposition

AS 13.52.065(a) requires the issuing clinician to document the grounds for the order in the patient's medical file.

☐ Order issued separately. I issued the operative order using current Alaska-compliant DNR or POLST materials and documented the grounds in the patient's medical file.

☐ No order issued. Further evaluation, discussion, consent, or documentation is required.

☐ Request declined. The statutory or clinical requirements for issuance are not satisfied.

Actual order or form title: [________________________________]

Order date: [__/__/____] Medical-record location: [________________________________]

Reason or follow-up plan:

[____________________________________________________________]

Clinician signature: [________________________________] Date: [__/__/____]

The signature above documents review of this worksheet. The separately issued DNR or POLST medical order—not this worksheet—is the operative order.

4. RECOGNITION AND IDENTIFICATION CHECKLIST

Alaska's current DNR protocol is in 7 AAC 16.010-.090. After confirming identity, the protocol directs providers to examine the patient, available medical records, and other sources to determine DNR status. Current recognition methods include the following, as applicable:

☐ Department-approved DNR form

☐ Department-approved DNR card

☐ Department-approved DNR necklace or bracelet

☐ Alaska POLST form adopted by reference in 7 AAC 16.020

☐ Written order from the attending physician, advanced practice registered nurse, or physician assistant

☐ Verbal order issued directly by the attending physician, advanced practice registered nurse, or physician assistant when permitted

☐ DNR, POLST, or MOLST order or identification from another U.S. jurisdiction that satisfies AS 13.52.150

Order or identification checked: [________________________________]

Location kept or worn: [________________________________]

Date patient, caregivers, facility, and transfer records were updated: [__/__/____]

Do not describe an item merely as “Comfort-One identification.” The current Alaska regulations use department-approved DNR identification and the Provider Orders for Life Sustaining Treatment (POLST) program.

5. WHAT THE DNR PROTOCOL DOES

• “Cardiopulmonary resuscitation” means an attempt to restore spontaneous circulation. A DNR order addresses emergency CPR; it does not automatically refuse every other treatment.
• Under 7 AAC 16.010, providers proceed with assessment and care, including CPR, while obtaining the required identity and DNR-status information. CPR need not be started or continued if the provider determines it would be futile.
• Once the provider establishes that the patient is a qualified DNR patient, the provider may not attempt CPR when the patient has no pulse or is not breathing. Other lawful, appropriate care is not affected by the DNR order.
• AS 13.52.060(i) permits resuscitation when the condition requiring it was precipitated by complications of medical services being provided. Under AS 13.52.060(j), that exception does not apply to field EMS unless an online physician orders resuscitation.
• AS 13.52.080 provides statutory protections for qualifying good-faith conduct, including withholding CPR under authorized clinical direction or upon discovery of DNR identification. Do not replace those statutory standards with a private release or indemnity clause.

6. REVOCATION OR CHANGE OF WISHES

Do not use this worksheet to revoke or amend an operative order.

Under AS 13.52.065(f), a DNR order may be made ineffective through:

• revocation by a physician, advanced practice registered nurse, or physician assistant;
• a request for revocation by the patient who has capacity; or
• for a patient under 18, a request for revocation by the patient's parent or guardian.

If the patient wants CPR or otherwise wants the order changed, immediately tell the treating clinician, caregivers, and facility. The clinician should document the request, revoke or replace the medical order as appropriate, and address all DNR identification and record copies.

Date change requested: [__/__/____]

Person notified: [________________________________]

Action taken and medical-record location:

[____________________________________________________________]

7. RECORDS AND TRANSFER CHECKLIST

☐ Separate clinician-issued DNR or Alaska POLST order is in the medical record

☐ Grounds for the order are documented in the medical file

☐ Current DNR identification or POLST form has been checked for accuracy

☐ Patient's advance directive and health-care agent information were reviewed for consistency

☐ Caregivers and the receiving facility know where the operative order or identification is kept

☐ Transfer packet and facility records contain the current order

☐ Superseded copies and identification were addressed after any revocation or replacement

A clinician-issued DNR order is distinct from a durable power of attorney for health care. The witness-or-notary rules in AS 13.52.010(b) apply to that separate power-of-attorney document; AS 13.52.065 governs issuance of the DNR order.

8. OFFICIAL SOURCES

• Alaska Health Care Decisions Act, AS 13.52.050-.160 — https://www.akleg.gov/basis/statutes.asp?media=print&secStart=13.52.050&secEnd=13.52.160
• Alaska definitions, AS 13.52.300-.395 — https://www.akleg.gov/basis/statutes.asp?media=print&secStart=13.52.300&secEnd=13.52.395
• AS 13.52.140-.150, including out-of-jurisdiction DNR recognition — https://www.akleg.gov/basis/statutes.asp?media=print&secStart=13.52.140&secEnd=13.52.155
• Alaska DNR/POLST regulation amendments, effective May 26, 2024 — https://aws.state.ak.us/OnlinePublicNotices/Notices/View.aspx?id=215215
• Filed regulation attachment — https://aws.state.ak.us/OnlinePublicNotices/Notices/Attachment.aspx?id=147827
• Alaska Department of Health, Emergency Medical Services — https://health.alaska.gov/en/division-of-public-health/rural-community-health/emergency-medical-services-ems/

Verify the current statute, regulations, department-approved materials, and treating facility's protocol before relying on any DNR or POLST order.