Emergency Medical Services Do Not Resuscitate (Dnr) Form printable pdf download

EMS

DNR

INSTRUCTIONS

Purpose

be readily available to EMS personnel in order for the Order

to be honored. Resuscitation attempts may be initiated until

This standardized EMS-DNR Order (Order) has been devel-

the form (or EMS bracelet/medallion) is presented and the

oped by the EMS Bureau within the Epidemiology and Re-

sponse Division of the New Mexico Department of Health

identity of the patient is confirmed by the EMS personnel. It

(DOH). It is in compliance with Section 24-10B-4I, NMSA

is recommended that the white envelope containing the Or-

1978 which directs the EMS Bureau to develop a program to

der be located in an obvious place that is readily available to

authorize EMS providers to honor advance directives to with-

emergency responders.

hold or terminate care. The program is described fully in

NMAC 7.27.6. A copy may be obtained by calling the EMS

ONE SIGNED COPY should be retained by the physician

Bureau at 505-476-8200 or online at

and made part of the patient’s permanent medical record. Ad-

ditional copies should be made so that the Order can be

For covered persons in cardiac or respiratory arrest, resusci-

maintained in all of the appropriate medical records.

tative measures to be withheld include external chest com-

pressions, intubation, defibrillation, administration of car-

ONE SIGNED COPY of the form may be used by the pa-

diac medications and artificial respiration. The Order does

tient to order an optional EMS bracelet or neck medallion

not effect the provision of other emergency medical care,

inscribed with the words “DO NOT RESUSCITATE - EMS”

including oxygen administration, suctioning, control of

The MedicAlert Foundation (2323 Colorado Avenue, Tur-

bleeding, administration of analgesics and comfort care.

lock, CA 95382) is the EMS Bureau approved supplier of the

medallions, which will be issued only upon receipt of the

Applicability

properly completed Order (together with an enrollment form

and the appropriate fee). If a MedicAlert enrollment form is

This Order applies only to resuscitation attempts by health

1.888.633.4298

and ask for an EMS-DNR

needed, call

care providers in the prehospital setting --i.e., in patients’

form. The fee can be waived for patients who cannot afford

homes, in a long term care facility, during transport to or

it, as certified by the physician or the physician’s designee.

from a heath care facility, or in other locations outside acute

Although optional, use of an EMS-DNR bracelet facilitates

care hospitals.

prompt identification of the patient and therefore is strongly

encouraged.

Instructions

Revocation

Any adult person may execute an Order in conjunction with

An Order may be revoked at any time orally or by perform-

a physician. The physician, or physician’s designee, shall

ing an act such as burning, tearing, canceling, obliterating or

explain to the person the full meaning of the Order, the

by destroying the order of any part of it by the person on

available alternatives and how the Order may be revoked.

whose behalf it was executed or by the persons’ authorized

Both the physician, or the physician’s designee upon a ver-

health care decision maker. If an Order is revoked, the pa-

bal order from the physician, and the person for whom the

tient’s physician should be notified immediately and all cop-

Order is executed, shall sign the Order.

ies of the form should be destroyed, including any copies on

file with MedicAlert Foundation. All medallions and associ-

If the person for whom the Order is contemplated is unable

ated wallet cards should be destroyed.

to give informed consent, or is a minor, the physician, or

physician’s designee, shall provide the same explanation of

Additional Resources available

the Order, the available alternatives, and how the Order

To obtain a New Mexico Durable Power of Attorney for

may be revoked to an authorized heath care decision maker.

Health Care Decision Form or a Values History Form, contact

If the authorized health care decision maker gives informed

the Center for Health Law and Ethics, 1111 Stanford, N.E.,

consent, both the physician, or the physician’s designee

Albuquerque NM 87131 or call 505-277-5006. The cost for

upon a verbal order from the physician, and the authorized

the Values form is $3.00 and may be requested in English or

health care decision maker shall sign the document

Spanish.

EMS-DNR forms may be downloaded from the EMS Bu-

ONE SIGNED COPY of the Order should be retained by

reau’s website, For DNR program im-

the patient and placed in an envelope. Staple the Envelope

plementation questions, please call the EMS Bureau at

Cover Sheet ( which is included in this PDF document ) “EMS

505-476-8200 .

DNR Order inside” to the envelope. The completed form

(and/or the approved EMS bracelet or neck medallion) must

Emergency Medical Services Do Not Resuscitate (Dnr) Form

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