If I sign a Do Not Resuscitate (DNR or DNAR) and thereafter go to another facility will they honor my wishes?

I have written several times after questions were posed regarding Advance Health Care Directives (Living Will plus Health Care Proxy appointment). An Advance Health Care Directive does not address a Do Not Resuscitate (DNR) or a Do Not Attempt Resuscitation (DNAR) order. Other health care facilities that receive a patient from one facility to another, whether it is for a period of time or for appointments not offered as a service in their facility must decide whether they can or should honor a DNR/ DNAR at their facility. For instance, say that a patient requires proton therapy at UAB. The trip to UAB from Montgomery would likely be by ambulance which may take 1 1/2 hours. Say during that time, the patient goes into cardiac arrest. If prior to transport the ambulance company was told the patient is a “no code” (no DNR/ DNAR) and therefore must decide whether to attempt resuscitation when that occurs during the trip. Did the ambulance company receive a copy of the DNR/ DNAR order? Are they willing to follow the order and do nothing while the patient dies? Is the ambulance company able to provide appropriate comfort care to the patient? Is the ambulance company liable if they do nothing to try and resuscitate the patient?

Those are a lot of sticky questions that the ambulance company has to be certain about prior to transport should a sudden and unexpected cardiac arrest occur.

The original Alabama Natural Death Act only addressed the Advance Directive which consists of the Living Will component and the naming of a health care proxy. In 2016, the Alabama legislature amended it to include a portable Alabama DNAR document. Portable means it can be transferred between facilities provided that the language is the same as in the Alabama Code section and meets all other statutory requirements. If an Alabama portable DNAR form comes from another state it can be accepted but it is up to the facility to verify that the physician that signs it has a legal medical license in the state in which they practice. A DNAR of any form for use in another state is never acceptable. An Alabama DNAR may have its company logo added, etc. or patient information added with facility identifiers provided as above in that the Alabama statutory language is identical or otherwise approved by the Committee of Public Health. It is advisable that the authentication time should be printed after the physician’s signature and also it is helpful to add something like the physician’s identification number or other identifier so that there is no confusion on who signed it.

The document has five sections. The document must have either section 1, 2, 3 OR 4 completed as well as section 5 completed. Section 1 allows a competent patient to sign the document if they do not want to be resuscitated or resuscitation attempted. The Alabama Public Health FAQ provides the following language; First, that the: “..patient/resident is not competent or is no longer able to understand, appreciate, and direct his/her medical treatment and has no hope of regaining that ability.”

Secondly: “A duly executed Advance Directive for Health Care with instructions that

no life sustaining treatment be provided was previously authorized by the

patient/resident and is part of his/her medical record.”

It is not necessary that this section is signed by a physician. A person such as a licensed

administrator, a social worker, PA or CRNP, a nurse or other facility representative who is authorized to review the medical record and attest to the documentation in the medical

record could sign that these statements are true and correct.

Section 3 allows one named as a proxy under an appropriate Advance Directive for Health Care or legal Alabama Health Care Power of Attorney to sign. If no one is available above then Section 4 allows for a family member to sign an appropriate Alabama Surrogate form found at https://www.alabamapublichealth.gov/providerstandards/assets/certificationhealthcaredecisionssurrogate.pdf.

Finally, Section 5 provides that a physician authorize the withholding of resuscitation, the administration of comfort care and the support of family and friends.

The Alabama Portable DNAR form is provided at https://www.alabamapublichealth.gov/ems/assets/dnar.form.010317.pdf.

This article is informative only and not meant to be all inclusive. Additionally this article does not serve as legal advice to the reader and does not constitute an attorney- client relationship. The reader should seek counsel from their attorney should any questions exist.

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