Medical Directive - DNR

ALABAMA DNAR REQUEST AND CLINICAL WORKSHEET

Not a Portable Physician DNAR Order or Advance Directive

CRITICAL NOTICE: Signing this worksheet does not create a portable or facility-specific Alabama DNAR order. Alabama's portable order is the State Board of Health form required by Ala. Admin. Code r. 420-5-19-.02. The applicable consent section and the physician-authorization section of that form must be completed.

Use this worksheet to prepare for a goals-of-care discussion, identify the proper decision-maker and supporting records, and document follow-up with the physician who will decide whether to issue the separate order.

1. PATIENT OR RESIDENT INFORMATION

2. REQUEST FOR DISCUSSION

I request a discussion with my attending physician about whether a portable or facility-specific DNAR order is appropriate.

My current goals and preferences are:

☐ If I am found without a pulse or respiration, I do not want resuscitative measures attempted if a physician issues a valid DNAR order for me.

☐ I want comfort care and treatment before cardiopulmonary cessation discussed separately from DNAR status.

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

[____________________________________________________________]

[____________________________________________________________]

Patient or information-provider signature: [________________________________]

Printed name and relationship: [________________________________]

Date: [__/__/____]

This signature records a request for review only. It is not the consent or physician authorization required on the official portable DNAR form.

3. IDENTIFY THE APPLICABLE CONSENT PATH

The Alabama Portable Physician Do Not Attempt Resuscitation Order contains four alternative consent paths. Complete and retain the records required for the path that applies; do not combine or invent a different signature process.

Path I — competent patient or resident

☐ The patient or resident will personally complete the official form's patient-consent section after discussing the decision and consequences with the physician.

Path II — prior advance-directive instructions

☐ The patient or resident is not competent, or can no longer understand, appreciate, and direct treatment and has no hope of regaining that ability.

☐ A duly executed advance directive instructing that no life-sustaining treatment be provided is already part of the medical record.

☐ A provider or facility representative will complete the certification required by the official form.

Path III — health-care proxy or attorney-in-fact

☐ A health-care proxy or attorney-in-fact has authority to decide whether life-sustaining treatment will be provided, withheld, or withdrawn.

☐ The document granting that authority is part of the medical record.

Path IV — certified surrogate

☐ A surrogate has been certified to make the decision in consultation with the attending physician.

☐ The completed Certification of Health Care Decision Surrogate is part of the medical record.

Decision-maker name: [________________________________]

Authority and supporting document: [________________________________]

Medical-record location: [________________________________]

The portable DNAR form itself does not contain a witness or notary block. Separate advance-directive, power-of-attorney, or surrogate-certification documents have their own execution requirements and must be reviewed independently.

4. PHYSICIAN REVIEW AND DISPOSITION

Physician name: [________________________________]

Alabama license number: [________________________________]

Review date: [__/__/____]

☐ I confirmed the patient's identity and reviewed the applicable consent path and supporting record.

☐ I discussed cardiopulmonary cessation, resuscitative measures, reasonable alternatives, comfort care, and the patient's goals with the patient or authorized decision-maker.

☐ Portable order issued separately. I completed the current State Board of Health Alabama Portable Physician DNAR Order and placed it in the medical record.

☐ Facility-specific order issued separately. I entered a facility-specific written DNAR order in the medical record. I understand that it does not transfer with the patient to another facility under r. 420-5-19-.02(5).

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

Reason or follow-up plan:

[____________________________________________________________]

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

The physician's signature above documents review of this worksheet. The separately completed official portable form or separately entered facility-specific order—not this worksheet—is the operative medical order.

5. PORTABILITY AND TRANSFER

Under Ala. Admin. Code r. 420-5-19-.02:

• a portable physician DNAR order must use the required State Board of Health form, with all applicable sections completed;
• qualified EMS personnel and licensed health-care practitioners may follow a portable order that is available, known to them, and executed under the rule;
• a transferring facility must tell the receiving facility about the order and ensure that a copy accompanies the patient; and
• the receiving facility must place the order in the patient's permanent medical record.

Transfer checklist:

☐ Current portable physician DNAR form checked for completeness

☐ Copy placed in transfer packet

☐ Receiving facility notified before or during transfer

☐ Receiving facility confirmed placement in permanent medical record

☐ Patient, family, and caregivers told where the operative order is kept

6. SCOPE OF THE OFFICIAL ORDER

The State Board of Health portable form directs personnel to withhold the following in the event of cardiopulmonary cessation:

• cardiopulmonary resuscitation and chest compression;
• endotracheal intubation and other advanced-airway management;
• artificial ventilation;
• cardiac resuscitative medications; and
• cardiac defibrillation.

The same form directs reasonable comfort care, including oxygen, suction, bleeding control, authorized pain medication, other comfort therapies, and support for the patient and others present.

Do not use private indemnity, release, default, attorneys' fees, forum-selection, or force-majeure clauses to change the medical order or the legal standards governing providers.

7. VERBAL DNAR ORDERS

Ala. Admin. Code r. 540-X-9-.13, effective August 12, 2024, permits a limited verbal-order process when the attending physician cannot timely go to the facility and the patient's decision is known but no DNAR order is yet in the medical record.

For a verbal order under that rule:

• the attending physician must issue it directly to a health-care provider physically at the same facility as the patient;
• the good-faith and decision-authority conditions in the rule must be satisfied;
• the physician must enter the completed portable form or facility-specific order in the medical record within 72 hours for the verbal order to remain valid; and
• written direction from a proxy, attorney-in-fact, or surrogate must also be placed in the record within 72 hours when that direction supports the order.

Verbal order issued: ☐ No ☐ Yes, on [__/__/____ at __:__]

Receiving provider and facility: [________________________________]

Written order entered by deadline: ☐ Not applicable ☐ Yes ☐ No

Supporting written direction entered by deadline: ☐ Not applicable ☐ Yes ☐ No

8. REVOCATION OR CHANGE OF WISHES

Do not use this worksheet to revoke an operative order. Portable orders remain effective until revoked under Ala. Code § 22-8A-5 or by another recognized means.

If the patient or authorized decision-maker wants resuscitation or otherwise wants the order changed, immediately notify the attending physician, caregivers, and facility. Document the communication, update the medical record, and address all copies of the portable or facility-specific order.

Date change requested: [__/__/____]

Person notified: [________________________________]

Action taken and medical-record location:

[____________________________________________________________]

9. OFFICIAL SOURCES

• Alabama Legislature, Code of Alabama, Title 22, Chapter 8A — https://alison.legislature.state.al.us/code-of-alabama?section=22-8A-3
• Ala. Admin. Code r. 420-5-19-.02, Portable Physician DNAR Orders — https://admincode.legislature.state.al.us/api/rule/420-5-19-.02
• Ala. Admin. Code r. 540-X-9-.13, Physician-Issued Verbal DNAR Orders — https://admincode.legislature.state.al.us/api/rule/540-X-9-.13
• Alabama Department of Public Health, Advance Directives — https://www.alabamapublichealth.gov/providerstandards/advance-directives.html
• Alabama Portable Physician Do Not Attempt Resuscitation Order — https://www.alabamapublichealth.gov/ems/assets/dnar.form.010317.pdf

Verify the current statute, rules, official form, and treating facility's protocol before relying on any DNAR order.