Free Arkansas Do Not Resuscitate Form Download

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ARKANSAS STATE BOARD OF HEALTH

OFFICE OF EMERGENCY MEDICAL SERVICES AND TRAUMA SYTEMS

RULES AND REGULATIONS FOR

EMERGENCY MEDICAL SERVICES DO NOT RESUSCITATE

Promulgated Under the Authority of (Act 1101 of 1993)

Effective Date April 1995 This Revision Effective July 2005

By the Arkansas State Board of Health

Division of Health Little Rock, Arkansas

Paul K. Halverson, DrPH, Director

RULES AND REGULATIONS PERTAINING TO

EMERGENCY MEDICAL SERVICES DO NOT RESUSCITATE

TABLE OF CONTENTS

1. Authority and Definitions 3

2. Requirements and Provisions 5

   Emergency Medical Services Do Not Resuscitate Form 5

3. Implementation Procedures 6

   Issuance of an EMS/DNR Order 6

   EMS Do Not Resuscitate Implementation Procedures 6

   General Considerations 6

4. Repeal 7

5. Certification of Rules and Regulations 7

6. DNR Form 8

RULES AND REGULATIONS PERTAINING

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TO

EMERGENCY MEDICAL SERVICES DO NOT RESUSCITATE

SECTION I. AUTHORITY

The following Rules and Regulations Pertaining to Emergency Medical Services are duly adopted and promulgated by the Arkansas State Board of Health pursuant to the authority expressly conferred by Act 1101 of 1993 (Ark. Code Ann. § 20-13-901 et seq.) and the laws of the State of Arkansas including without limitation, Act 96 of 1913 (Ark. Code Ann. § 20-7-109)

DEFINITIONS

1.1 - Definitions:

The following words and terms, when used in these regulations, shall have the following meaning unless the context clearly indicates otherwise:

“Ambulance Service” means those services authorized and licensed by the Department to provide care and transportation of patients upon the streets and highways of Arkansas.

"Attending Physician" means the physician who has the primary responsibility for the treatment and care of the patient.

"Board" means the State Board of Health.

"Cardiac Arrest" means the cessation of a functional heartbeat.

"Cardiopulmonary Resuscitation" means medical procedures including: cardiac compression, endotracheal intubation and other advanced airway management, artificial ventilation, defibrillation, administration of cardiac resuscitation medications, and related procedures.

"Department" means the Division of Health. "Director" means the State Health Division Director.

"Emergency Medical Services (EMS)" means the transportation and medical care provided the ill or injured prior to arrival at a medical facility by a certified emergency medical technician (EMT) or other healthcare provider and continuation of the initial emergency care within a medical facility subject to the approval of the medical staff and governing board of that facility.

"Emergency Medical Services Do Not Resuscitate Order ("EMS/DNR Order") means a written

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physician's order in a form consistent with section 2.1 which authorizes emergency medical services personnel to withhold or withdraw cardiopulmonary resuscitation from a particular patient in the event of cardiac or respiratory arrest.

"Emergency Medical Services Personnel" ("EMS Personnel") means paid or volunteer firefighters, law enforcement officers, first responders, emergency medical technicians, or other emergency personnel acting within the ordinary course of their professions.

“Emergency Medical Services Do Not Resuscitate (“EMS/DNR”) Order Implementation Protocol” means a set of instructions developed by the emergency medical service provider to respond to emergency medical needs and approved by the Medical Director of the Emergency Medical Services provider.

“EMS/DNR Order Form” means a document as approved by the Board, or one created or used by a physician that is consistent with these regulations.

"Health Care Proxy" is a person eighteen (18) years old or older appointed by the patient as attorney-in-fact to make health care decisions including the withholding or withdrawal of life- sustaining treatment If a qualified patient, In the opinion of the attending physician, Is permanently unconscious, incompetent, of otherwise mentally or physically incapable of communication, as specified in AR Statutes 20-17-201(10).

“No Code or DNR” means an instruction or order to withhold cardiopulmonary resuscitation (cardiac compression, endotracheal intubation and other advanced airway management, artificial ventilation, defibrillation, administration of cardiac resuscitation medications, and related procedures) from the patient in the event of the patient’s cardiac or respiratory arrest.

"Respiratory Arrest" means cessation of breathing.

SECTION II REQUIREMENTS AND PROVISIONS

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General Provisions

1. - The Emergency Medical Services Do Not Resuscitate Order Form:

   
   

   The EMS/DNR Order Form shall be a document as approved by the Board, or one created or used by a physician that is consistent with these regulations. The following requirements and provisions shall apply to any EMS/DNR Order Form.

   
   

   1. Content of the Form - A valid EMS/DNR Order Form shall include the words “DNR” or “No Code,” or similar language, and the physician’s signature and the date.

      
      

   2. Copies of the EMS/DNR Order Form may be given to other providers or persons for information.

      
      

   3. Revocation of an EMS/DNR Order - An EMS/DNR Order may be revoked at any time or in any manner by the named patient or patient’s attending physician.

      
      

   4. Distribution of EMS/DNR Order Forms - EMS/DNR Forms approved by the Board, with instructions, shall be available to physicians through local Health Department offices, local hospitals, ambulance services, and to private physicians, on request. Other distribution points may be approved by the Director to meet identified needs.

SECTION III IMPLEMENTATION PROCEDURES

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1. - Issuance of an EMS/DNR Order:

   
   

   An EMS Do Not Resuscitate Order may only be issued by the patient’s attending physician.

   
   

2. - EMS Do Not Resuscitate Implementation Procedures:

   
   

   Emergency Medical Services personnel shall comply with the EMS/DNR Order implementation protocols when responding to a patient who is in cardiac or respiratory arrest and who is known to have an EMS/DNR Order in effect as approved by the Department.

   
   

3. - General Considerations

The following general principles shall apply to implementation of EMS Do Not Resuscitate Orders:

If there is misunderstanding with family members or others present at the scene or if there are other concerns about following the EMS/DNR Orders, contact the attending physician or EMS medical control for guidance. If there is any question about the validity of an EMS/DNR Order, resuscitate.

SECTION IV. REPEAL

4.1 All Regulations and parts of Regulations in conflict herewith are hereby repealed.

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SECTION V.

CERTIFICATION

This will certify that the foregoing Rules and Regulations for Emergency Medical Services Do Not Resuscitate were adopted by the Arkansas Board of Health at a regular session of said Board held in Little Rock, Arkansas on the Twenty-eighth day of July, 2005.

Paul K. Halverson, DrPH Director, Division of Health

The forgoing Rules and Regulations, copy having been filed in my office, are hereby approved on this

day of , 2005.

Mike Huckabee Governor

NO CPR

DO NOT RESUSCITATE

DNR

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STATE OF ARKANSAS EMERGENCY MEDICAL SERVICES DO NOT RESUSCITATE ORDER

Patient's Full Name:

Signature of Patient or Health Care Proxy or Legal Guardian Date

ATTENDING PHYSICIAN'S ORDER

I, the undersigned, state that I am the physician for the patient named above.

I hereby direct any and all qualified Emergency Medical Services personnel, commencing on the effective date noted below, to withhold cardiopulmonary resuscitation (cardiac compression, endotracheal intubation and other advanced airway management, artificial ventilation, defibrillation, administration of cardiac resuscitation medications, and related procedures) from the patient in the event of the patient's cardiac or respiratory arrest. I further direct such personnel to provide to the patient other medical interventions such as intravenous fluids, oxygen, or other therapies deemed necessary to provide comfort care or alleviate pain.

Signature of Attending Physician

Physician’s Telephone number (emergency #)

Physician's Printed/Typed Name

Date Order Written

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