"Emergency Medical Services Do Not Resuscitate (DNR) Form" - New Mexico

Emergency Medical Services Do Not Resuscitate (DNR) Form is a legal document that was released by the New Mexico Department of Health - a government authority operating within New Mexico.

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Download "Emergency Medical Services Do Not Resuscitate (DNR) Form" - New Mexico

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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 www.nmems.org.
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, www.nmems.org. 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
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 www.nmems.org.
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, www.nmems.org. 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
ENVELOPE
COVER SHEET
EMS
DNR
ORDER INSIDE
Note: Staple this cover sheet to the envelope containing the signed EMS-DNR Order.
EMS
DNR
EMERGENCY MEDICAL SERVICES (EMS)
DO NOT RESUSCITATE (DNR) FORM
AN ADVANCE DIRECTIVE TO LIMIT THE SCOPE OF EMS CARE
NOTE: THIS ORDER TAKES PRECEDENCE OVER A DURABLE HEALTH CARE POWER OF ATTORNEY FOR EMS TREATMENT ONLY
I, _______________________________, request limited EMS care as described in this document. If
my heart stops beating or if I stop breathing, no medical procedure to restore breathing or heart func-
tioning will be instituted, by any health care provider, including but not limited to EMS personnel.
I understand that this decision will not prevent me from receiving other EMS care, such as oxygen and
other comfort care measures.
I understand that I may revoke this Order at any time.
I give permission for this information to be given to EMS personnel, doctors, nurses and other health
care professionals. I hereby agree to this DNR order.
_________________________
OR
______________________________
Signature
Signature/Authorized
Health Care Decision Maker
I affirm that this patient/authorized health care decision maker is making an informed decision and that
this is the expressed directive of the patient. I hereby certify that I or my designee have explained to
the patient the full meaning of the Order, available alternatives, and how the Order may be revoked. I
or my designee have provided an opportunity for the patient/authorized health care decision maker to
ask and have answered any questions regarding the execution of this form. A copy of this Order has
been placed in the medical record. In the event of cardiopulmonary arrest, no chest compressions, arti-
ficial ventilations, intubation, defibrillation, or cardiac medications are to be initiated.
________________________________________
_____________________________________
Physician’s Signature/Date
Physician’s Name—PRINT
_______________________________________________________________________________
Physician’s Address/Phone
Note: please print three (3) copies
ONE SIGNED COPY: To be kept by patient in white envelope and immediately available to Emergency Responders
ONE SIGNED COPY: To be kept in patient’s permanent medical record
ONE SIGNED COPY: If DNR Bracelet/Medallion is desired send to MedicAlert with enrollment form
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