Do-Not-Resuscitate Identification Application - Adult Form - Southern Nevada Health District Page 2
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1
2APPLICANT INSTRUCTIONS
The 1997 Legislature enacted Assembly Bill 29,
allowing “qualified patients” to apply for a Do-Not-
Resuscitate identification. DNR Identification instructs
1. Provide the information required in the
prehospital emergency medical service personnel to
“Patient Information” section of the
withhold life-resuscitating treatment in the event of
application.
cardiac or respiratory arrest. EMS personnel will
provide appropriate emergency medical and supportive
2. Sign and date the “Patient’s Statement”
care to patients with DNR Identification if the patient is
or “Agent’s Statement” section of the
not experiencing cardiac or respiratory arrest.
application.
A “qualified patient” is a patient who has executed a
3. Have your attending physician complete
declaration, in accordance with NRS 449.600,
governing the withholding or withdrawal of life-
and sign the “Attending Physician’s
DO-NOT-RESUSCITATE
sustaining treatment and who has been determined by
Statement” on the application.
his attending physician to be a terminal condition.
4. Mail the completed application to:
IDENTIFICATION
Do-Not-Resuscitate Identification will be a card and
document issued by the Southern Nevada Health
Southern Nevada Health District
District signifying the person is a qualified patient who
Office of EMS & Trauma System
wishes not to be resuscitated in the event of cardiac or
APPLICATION
P.O. Box 3902
respiratory arrest. NRS 450B.410.
Las Vegas, NV 89127
Life-resuscitating treatment means cardiopulmonary
resuscitation (CPR) or any of its components including
ADULT (18+ YEARS OF AGE)
5. Submit a check or money order in the
chest compressions, defibrillation, cardioversion,
amount of $5.00, payable to the Southern
assisted ventilation, airway intubation and
Nevada Health District, with the
administration of cardiac medications.
completed application.
Patients applying for Do-Not-Resuscitate Identification
ATTENDING PHYSICIAN’S
should fully discuss their decision with their family
INSTRUCTIONS
members or caretakers. Family members or caretakers
are generally the ones who call EMS when the patient
Complete the “Attending Physician’s
needs medical assistance. Being aware and supportive
Statement” by:
of the patient’s wishes in this area allows them to
appropriately advise EMS personnel responding to care
for the patient.
1. Providing your name, telephone number,
license number; and
Southern Nevada Health District
Office of EMS & Trauma System
2. Signing the “Attending Physician’s
P.O. Box 3902
Statement” where indicated.
For additional information please call:
Las Vegas, NV 89127
Southern Nevada Health District EMS
(702) 759-1050
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