Medical Directive - DNR

CALIFORNIA PREHOSPITAL DNR REQUEST AND CLINICAL WORKSHEET

Not the EMSA Prehospital DNR Form, POLST, or Facility Order

CRITICAL NOTICE: Signing this worksheet does not create a California request regarding resuscitative measures. Under Probate Code § 4780, the operative written request must be signed by the individual with capacity or legally recognized health care decisionmaker and the individual's physician. Use the current California Emergency Medical Services Authority (EMSA) form or another substantially similar compliant form.

Use this worksheet to prepare for discussion and execution of the actual prehospital DNR form.

1. PATIENT INFORMATION

2. REQUEST FOR DISCUSSION

I request a discussion with my physician about completing a California prehospital DNR form.

If I experience cardiopulmonary arrest, my current preference is to forego the resuscitative measures listed on the EMSA form, including chest compressions, assisted ventilation, endotracheal intubation, defibrillation, and cardiotonic drugs.

I understand that the prehospital DNR does not control artificial nutrition or hydration and does not withhold other emergency care, including palliative treatment for pain, breathing discomfort, major hemorrhage, or other medical conditions.

Questions, values, or treatment preferences:

[____________________________________________________________]

[____________________________________________________________]

Patient or information-provider signature: [________________________________]

Printed name and relationship: [________________________________]

Date: [__/__/____]

This signature records preparation only. Complete the signatures on the actual EMSA form.

3. PATIENT OR LEGALLY RECOGNIZED DECISIONMAKER

Signer: ☐ Patient with capacity ☐ Legally recognized health care decisionmaker

If the patient cannot make or communicate an informed decision, confirm authority under current California law. Probate Code § 4712 recognizes, in order, a patient-selected surrogate under § 4711, an agent under an advance directive or health-care power of attorney, and a conservator or guardian with health-care authority. If none exists, a provider or facility designee may choose an eligible surrogate under § 4712(b).

Decisionmaker name: [________________________________]

Authority and supporting document: [________________________________]

Date and medical-record location: [________________________________]

☐ Patient capacity assessed

☐ Decisionmaker authority confirmed

☐ Patient's known wishes and other health-care instructions reviewed

Probate Code § 4715 is a patient-disqualification rule; it is not the surrogate hierarchy. Do not cite § 4715 as the source of decisionmaker priority.

4. PHYSICIAN REVIEW AND EXECUTION

Physician name: [________________________________]

California license number: [________________________________]

Review date: [__/__/____]

☐ I explained the nature and consequences of the DNR instruction and reasonable alternatives.

☐ I confirmed informed consent from the patient or legally recognized decisionmaker.

☐ Prehospital DNR completed separately. The patient or decisionmaker and physician signed the current EMSA form or a substantially similar compliant form.

☐ POLST considered or completed separately. The patient needs broader portable medical orders regarding resuscitative and life-sustaining treatment.

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

Reason or follow-up plan:

[____________________________________________________________]

Physician signature on this worksheet: [________________________________] Date: [__/__/____]

The signature above documents review of this worksheet. The separately completed request—not this worksheet—is the operative document. The EMSA prehospital DNR form requires a physician signature. A POLST may be signed by a physician or, within the conditions stated in § 4780(c), a nurse practitioner or physician assistant.

5. WHAT THE PREHOSPITAL DNR DOES

• It instructs EMS personnel about withholding listed resuscitative measures after cardiopulmonary arrest.
• It was designed for prehospital settings, including a patient's home, long-term care, transport, and other locations outside acute-care hospitals.
• Hospitals are encouraged to honor the form when the patient reaches an emergency room, but the EMSA instructions state that it does not replace DNR orders required by a facility's own policies and procedures.
• Resuscitation may begin until the completed form or approved medallion is presented and the patient's identity is confirmed.

Do not state that signing a private template automatically creates a facility physician order.

6. FORM, RECORDS, AND AVAILABILITY

Checklist for the operative EMSA form:

☐ Patient's full legal name completed

☐ Patient or legally recognized decisionmaker signed and dated

☐ Decisionmaker relationship or authority recorded

☐ Physician signed and dated

☐ Physician name, address, and telephone completed

☐ Form retained where EMS personnel can readily find it

☐ Physician retained the appropriate copy in the permanent medical record

☐ Family, caregivers, facility, and agent told where the form is kept

The current EMSA instructions do not require two witnesses or a notary for the prehospital DNR form. Those formalities may apply to a separate advance health care directive; do not import them into the EMSA DNR execution block.

Do not assume that an electronic image, electronic signature, fax, or PDF counterpart substitutes for the completed form under current law. A pending bill is not current law.

7. OPTIONAL EMSA-APPROVED MEDALLION

Probate Code § 4780(e) permits a request regarding resuscitative measures to be evidenced by a medallion that:

• is engraved with “do not resuscitate” or “DNR”;
• includes a patient identification number and a 24-hour toll-free telephone number; and
• is issued by a person operating under an agreement with EMSA.

The EMSA form instructions describe approved wrist or neck medallions. Do not treat an ordinary bracelet, necklace, wallet card, or self-printed tag as statutory evidence.

Approved supplier: [________________________________]

Patient identification number: [________________________________]

Date ordered or received: [__/__/____]

8. REVOCATION OR CHANGE OF WISHES

The EMSA form states that, absent contrary knowledge, a provider may presume a request is valid and unrevoked. If the decision is revoked:

• notify the patient's physician immediately;
• destroy all copies of the prehospital DNR form, including supplier copies; and
• destroy or return medallions and associated wallet cards to the supplier.

Probate Code § 4780(d) separately provides that a patient with capacity may revoke a POLST at any time and in any manner communicating an intent to revoke.

Do not use this worksheet as the revocation itself. Document the change in the medical record and remove every superseded item from active use.

Date change requested: [__/__/____]

Person notified: [________________________________]

Action taken and record location:

[____________________________________________________________]

9. GOOD-FAITH RELIANCE

Probate Code § 4782 protects a health care provider who honors a request regarding resuscitative measures when the provider believes in good faith that the action is consistent with the statute and has no knowledge that it conflicts with the decision the signer would have made under like circumstances. Probate Code § 4740 contains related good-faith protections for compliance with health-care decisions and directives.

Do not replace those statutory rules with indemnity, release, liability-cap, force-majeure, attorneys' fees, forum-selection, or private-remedies clauses.

10. OFFICIAL SOURCES

• California EMSA, Prehospital DNR Form — https://emsa.ca.gov/wp-content/uploads/sites/71/2017/07/DNRForm.pdf
• Cal. Prob. Code § 4780 — https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=4780.&lawCode=PROB
• Cal. Prob. Code § 4781 — https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=4781.&lawCode=PROB
• Cal. Prob. Code § 4782 — https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=4782.&lawCode=PROB
• Cal. Prob. Code § 4712 — https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=4712.&lawCode=PROB
• Cal. Prob. Code § 4740 — https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=4740.&lawCode=PROB

Verify the current statutes, EMSA form, approved medallion supplier, and local EMS or facility protocol before relying on any DNR request.