Medical Directive - DNR

ARKANSAS POLST / EMS-DNR REQUEST AND CLINICAL WORKSHEET

Not a POLST, EMS/DNR Order, or Advance Directive

CRITICAL NOTICE: Signing this worksheet does not create an Arkansas DNR order. The current Arkansas POLST is a physician order requiring both the physician's signature and the signature of the patient or legal representative. The separate EMS/DNR rule also requires a written attending-physician order.

Use this worksheet to prepare for a goals-of-care discussion, identify the appropriate decision-maker, and collect information for the physician who will complete the operative form.

1. PATIENT INFORMATION

2. REQUEST FOR DISCUSSION

I request a discussion with my physician about whether an Arkansas POLST or EMS/DNR order is appropriate for my medical condition and goals.

My current preferences are:

☐ If I am found without a pulse and not breathing, I prefer “Do Not Attempt Resuscitation/DNR (Allow Natural Death),” if a physician issues a valid order.

☐ If I still have a pulse or am breathing, I want the separate medical-intervention choices on the POLST form explained.

☐ I want comfort treatment, transfer preferences, nutrition and hydration, and other medical orders discussed separately from CPR status.

Questions, values, or treatment preferences:

[____________________________________________________________]

[____________________________________________________________]

Patient or information-provider signature: [________________________________]

Printed name and relationship: [________________________________]

Date: [__/__/____]

This signature documents a request for discussion only. No patient is required to complete a POLST, and the official form's required signatures must be completed voluntarily on that form.

3. PATIENT OR LEGAL REPRESENTATIVE

The physician should confirm whether the patient has capacity. If the patient lacks capacity, the current POLST directions permit a legal representative to sign. The directions identify possible representatives including a court-appointed guardian, an agent designated in an advance directive, a spouse, an adult child, an adult sibling, an adult relative, or another surrogate meeting the stated care, familiarity, and decision-making criteria.

Signer: ☐ Patient with capacity ☐ Legal representative

Legal representative name: [________________________________]

Relationship or authority: [________________________________]

Supporting document, if any: [________________________________]

Medical-record location: [________________________________]

☐ Current advance directive located and reviewed for consistency

☐ Conflicts between the advance directive and proposed POLST orders addressed

POLST complements but does not replace an advance directive. The POLST form requires the physician and patient or legal representative to sign; it does not require the witness or notary blocks used for a separate advance directive.

4. PHYSICIAN REVIEW — COMPLETE ON THE OFFICIAL FORM

Physician name: [________________________________]

Arkansas license number: [________________________________]

Review date: [__/__/____]

☐ I discussed the patient's illness, prognosis, treatment preferences, values, and goals with the patient or legal representative.

☐ I reviewed medical indications and the patient's advance directive, if available.

☐ POLST completed separately. I completed the current Arkansas Department of Health POLST form and obtained both required signatures.

☐ EMS/DNR order completed separately. I issued a written order consistent with the State Board of Health EMS/DNR rule.

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

Reason or follow-up plan:

[____________________________________________________________]

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

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

5. POLST ORDER CHECKLIST

Complete the selections only on the current official form.

Section A — CPR when pulseless and not breathing

☐ Attempt Resuscitation/CPR

☐ Do Not Attempt Resuscitation/DNR (Allow Natural Death)

Choosing CPR in Section A requires Full Treatment in Section B. When DNR is selected, the current directions state that defibrillation and chest compressions should not be used if the patient is pulseless and not breathing.

Section B — interventions when the patient has a pulse or is breathing

☐ Full Treatment

☐ Selective Treatment

☐ Comfort Treatment

Section C — additional orders

Additional orders should be written by the physician on the official form. The current directions recommend addressing food and drink by mouth and warn that local EMS protocol may not implement every additional order written in Section C.

Section D — information and signatures

☐ Discussion participant identified

☐ Advance-directive status recorded

☐ Physician signature and date completed

☐ Patient or legal-representative signature and date completed

☐ Physician contact and license information completed

6. COPIES, COLOR, RECORDS, AND TRANSFER

• Bright pink paper is recommended so the POLST is easy to recognize; it is not stated as a condition of validity.
• The original is encouraged, but the current Arkansas directions state that photocopies and faxes are legally valid.
• The POLST should be kept in the patient's chart or medical record and be immediately accessible.
• Send the form with the patient whenever the patient is transferred or discharged.
• On admission, the POLST establishes initial treatment until the accepting professional evaluates the patient and issues any additional orders consistent with the patient's preferences.

Checklist:

☐ Executed form checked for both required signatures

☐ Copy placed in chart or medical record

☐ Copy placed in transfer or discharge packet

☐ Patient, legal representative, caregivers, and receiving facility told where the form is kept

☐ Superseded forms clearly voided and removed from active-use locations

7. EMS/DNR RULE

The separately published State Board of Health EMS/DNR rule provides that:

• an EMS/DNR order may be issued only by the patient's attending physician;
• a valid form includes DNR, No Code, or similar language, the physician's signature, and the date;
• EMS personnel follow approved implementation protocols for a patient in cardiac or respiratory arrest who is known to have an effective order; and
• if validity is in question, personnel resuscitate and seek guidance from the attending physician or EMS medical control.

Do not use invented bracelet, necklace, special-color, wet-ink, electronic-signature, witness, or notary requirements in place of the current state order and protocol.

8. REVIEW, MODIFICATION, OR REVOCATION

The current POLST directions recommend review when the patient changes care settings or levels, experiences a substantial health-status change, or changes treatment preferences.

A patient with capacity may request alternative treatment or revoke the POLST by any means indicating intent to revoke. The directions recommend drawing a line through Sections A-C, writing “VOID,” and signing and dating the line. A legal representative for a patient without capacity may request modification after consulting with the physician, based on the patient's known desires or, if unknown, best interests. The Department of Health also states that a patient or legal proxy may revoke or void the form at any time.

Do not use this worksheet as the revocation itself. Immediately notify the physician and caregivers, document the change in the medical record, and address every active copy.

Date change requested: [__/__/____]

Person notified: [________________________________]

Action taken and record location:

[____________________________________________________________]

9. OFFICIAL SOURCES

• Arkansas Department of Health, POLST — https://healthy.arkansas.gov/programs-services/certificates-records/polst/
• Arkansas POLST Form and Directions — https://healthy.arkansas.gov/wp-content/uploads/POLST_Form_and_Directions.pdf
• Arkansas Department of Health, POLST Forms and Directions — https://healthy.arkansas.gov/programs-services/certificates-records/polst/polst-forms-directions/
• Arkansas State Board of Health, EMS Do Not Resuscitate Rules — https://healthy.arkansas.gov/wp-content/uploads/DnrRegs.pdf
• Arkansas Department of Health, Healthcare Decision Forms — https://healthy.arkansas.gov/boards-commissions/boards/health-arkansas-state-board-of/healthcare-decision-forms/

Verify the current statute, rules, official form, and local EMS or facility protocol before relying on any POLST or DNR order.