Scenario #1 (October 1999):
Mrs. Kahn was a nursing home patient with Alzheimer's dementia. After discussion with her family, Mrs. Kahn's physician wrote a Do Not Resuscitate (DNR) order in the nursing home chart. A family member also signed a DNR form used by the nursing home. One night her blood pressure dropped and she complained of chest pain. Aware that Mrs. Kahn was DNR, nursing home personnel called 911. They also agreed to withhold CPR if she arrested while awaiting transfer. Medics arrived and immediately located the doctor's DNR order, but not the nursing home DNR. Then Mrs. Kahn had a cardiac arrest. By law medics had to initiate cardiopulmonary resuscitation (CPR) while they phoned the Emergency Medical System (EMS) physician for an order to discontinue resuscitation efforts.

Scenario#2 (June 2000):
Mr. Dennis had severe inoperable coronary artery disease. Each month he visited his primary care physician for angina management. After extensive discussion with his doctor, Mr. Dennis completed a living will in which he clearly specified treatments he wanted to forgo. He also located the website of a medical society in a neighboring state and downloaded their DNR form. For "extra protection" he filled out this form and taped it to his refrigerator. One day while home alone Mr. Dennis experienced chest pain, called 911 and collapsed. Upon arrival medics saw the DNR document on the refrigerator, but in accordance with law they initiated CPR while contacting the EMS physician. Since the DNR form was from another state and was not signed by a doctor, the physician refused to authorize withholding CPR and Mr. Dennis was transported to the nearest hospital. He had a pulse but remains unresponsive. Mr. Dennis's family and physician agreed that the ventilator and other treatments should be withdrawn in accordance with his living will. Twelve hours after collapsing Mr. Dennis died, having received resuscitation and intubation he did not want.

A SOLUTION
Until this year patients like Mrs. Kahn and Mr. Dennis who suffered cardiac arrest outside the hospital were treated with full resuscitation by paramedics on the scene, whether or not this course represented appropriate medical care or their own wishes. The Illinois Department of Public Health (IDPH) has instituted a new out-of-hospital DNR form effective July 1, 2001. With the new form, paramedics who encounter cardiac arrest patients with complete and visible out-of-hospital DNR forms must withhold CPR.

Prior to existence of the new DNR form and procedures, EMS providers were required to initiate and continue CPR until the DNR order could be confirmed. Confirmation occurred by the medic contacting an EMS physician and relaying five elements (date, patient name, patient or proxy signature, physician signature, and presence of the phrase "do not resuscitate"). The EMS physician then made a decision on the appropriateness of CPR. During this process many patients received unwanted resuscitation. When patients survived CPR, families and providers had the burden of withdrawing this unwelcomed treatment.

The new IDPH DNR regulations improve patient control over resuscitation decisions. The form itself is standard, simple, and recognizable. Resuscitation pending confirmation of the order is a thing of the past. In fact, medics are now required to withhold CPR when they see that the order has been properly completed.

In order to minimize the possibility of unwanted CPR, patients and their providers should understand the importance of correctly completing the IDPH DNR form, which is printed on bright orange paper. The color facilitates quick recognition of the DNR form, reducing time that might be wasted searching for the order among numerous other orders and documents patients accumulate in the course of care.

The color is also essential to validity: even when the form is correctly completed, if it is not an orange original medics are required to initiate CPR and employ the previously used procedure for notifying an EMS physician and confirming the DNR order. This means that faxes and photocopies of orders should be avoided. Instead, completion of more than one orange original at a single point in time should be considered. (States with laws similar to Illinois regulations have eventually eased their "color originals only" requirement, but for now it is the rule in Illinois.)

The following information must be on the form for it to be valid: name and signature of the patient or legally recognized decision maker (if the latter, that person's address is also required), attending physician's name and signature, dates of signatures, and the names and signatures of two witnesses.

Although the IDPH DNR order is not labeled "for out of hospital use only," it should not be used as a substitute for in-hospital DNR physician orders. Unlike the IDPH form, in house DNR orders are crafted for specific institutions and often contain instructions for non-arrest critical situations in addition to DNR treatment. For convenience and thoroughness, therefore, when DNR status is warranted in and out of the hospital, the IDPH form should be completed at the same time the in-house order is written. This avoids delays in discharge for patients who wish to remain DNR when transferred to a nursing home or elsewhere.

Orange out-of-hospital DNR forms are supplied by IDPH to physicians and hospitals free of charge. The IDPH EMS Division can be reached by telephone at (217) 785-2080.