Outside the Hospital Do-Not-Resuscitate (OHDNR)

PURPOSE: This rule establishes a procedure to be followed by personnel to comply with the outside the hospital do-not-resuscitate protocol when presented with an outside the hospital do-not-resuscitate identification or an outside the hospital do-not-resuscitate order. (1) As used in this rule, the following terms shall mean— (A) “Attending physician”— 1. A physician licensed under Chapter 334, RSMo, selected by or assigned to a patient who has primary responsibility for treatment and care of the patient; or 2. If more than one (1) physician shares responsibility for the treatment and care of a patient, one (1) such physician who has been designated the attending physician by the patient or the patient’s representative shall serve as the attending physician; (B) “Cardiopulmonary resuscitation” or “CPR,” emergency medical treatment administered to a patient in the event of the patient’s cardiac or respiratory arrest and shall include cardiac compression, endotracheal intubation and other advanced airway management, artificial ventilation, defibrillation, administration of cardiac resuscitation medications, and related procedures; (C) “Department,” the Department of Health and Senior Services; (D) “Emergency medical services personnel,” paid or volunteer firefighters, law enforcement officers, first responders, emergency medical technicians, advanced emergency medical technicians, paramedics, or other emergency service personnel acting within the ordinary course and scope of their professions, but excluding physicians; (E) “Health care facility,” any institution, building, or agency or portion thereof, private or public, excluding federal facilities and hospitals, whether organized for profit or not, used, operated, or designed to provide health services, medical treatment, or nursing, rehabilitative, or preventive care to any person or persons. Health care facility includes but is not limited to ambulatory surgical facilities, health maintenance organizations, home health agencies, hospices, infirmaries, renal dialysis centers, long-term care facilities licensed under sections 198.003 to 198.186, RSMo, medical assistance facilities, mental health centers, outpatient facilities, public health centers, rehabilitation facilities, and residential treatment facilities; (F) “Hospital,” a place devoted primarily to the maintenance and operation of facilities for the diagnosis, treatment, or care for not less than twenty-four (24) consecutive hours in any week of three (3) or more nonrelated individuals suffering from illness, disease, injury, deformity, or other abnormal physical conditions; or a place devoted primarily to provide for not less than twenty-four (24) consecutive hours in any week medical or nursing care for three (3) or more nonrelated individuals. Hospital does not include any long-term care facility licensed under sections 198.003 to 198.186, RSMo; (G) “Outside the hospital do-not-resuscitate (OHDNR) identification” or “outside the hospital DNR identification,” a standardized identification card, bracelet, or necklace of a single color, form, and design that signifies that the patient’s attending physician has issued an outside the hospital do-not-resuscitate order for the patient and has documented the grounds for the order in the patient’s medical file; (H) “Outside the hospital do-not-resuscitate (OHDNR) order” or “outside the hospital DNR order,” a written physician’s order signed by the patient and the attending physician, or the patient’s representative and the attending physician, which authorizes emergency medical services personnel to withhold or withdraw cardiopulmonary resuscitation from the patient in the event of cardiac or respiratory arrest; (I) “Outside the hospital do-not-resuscitate (OHDNR) protocol” or “outside the hospital DNR protocol,” a standardized method or procedure for the withholding or withdrawal of cardiopulmonary resuscitation by emergency medical services personnel from a patient in the event of cardiac or respiratory arrest; (J) “Patient,” a person eighteen (18) years of age or older who is not incapacitated, as defined in section 475.010, RSMo, and who is otherwise competent to give informed consent to an OHDNR order at the time such order is issued, and who, with his or her attending physician, has executed an OHDNR order under sections 190.600 to 190.621, RSMo. A person who has a patient’s representative shall also be a patient for the purposes of sections 190.600 to 190.621, RSMo, if the person or the person’s patient’s representative has executed an OHDNR order under sections 190.600 to 190.621, RSMo. A person under eighteen (18) years of age shall also be a patient for purposes of sections 190.600 to 190.621, RSMo, if the person has had a do-not-resuscitate order issued on his or her behalf under the provisions of section 191.250, RSMo; and (K) “Patient’s representative”— 1. An attorney-in-fact designated in a durable power of attorney for health care for a patient determined to be incapacitated under sections 404.800 to 404.872, RSMo; 2. A guardian or limited guardian appointed under Chapter 475, RSMo, to have responsibility for an incapacitated patient; or 3. A patient under the age of eighteen (18) years may have an OHDNR order signed by at least one (1) parent, by at least one (1) of the patient’s legal guardian(s), or by a juvenile or family court under the provisions of section 191.250, RSMo, if the patient is under juvenile court jurisdiction under section 211.031, RSMo. (2) A properly executed OHDNR order— (A) Shall be completed on an OHDNR order form with an optional instruction form. The OHDNR order form and instruction form are included herein and available at the Emergency Medical Services Bureau office, online at www.dhss.mo.gov/ EMS, or obtained by mailing a written request to the Missouri Department of Health and Senior Services, EMS Bureau, PO Box 570, Jefferson City, MO 65102-0570. The instruction form may be photocopied on the back side of the OHDNR order form or attached as a separate page to the OHDNR order form; (B) Shall only be effective when the patient has not been admitted to or is not being treated within a hospital or has not yet come to the emergency department as defined in the Emergency Medical Treatment and Active Labor Act (EMTALA), 42 U.S.C. section 1395dd, and the regulation 42 CFR section 489.24(a) and referenced in the Centers for Medicare & Medicaid Services State Operations Manual Appendix V – Interpretive Guideline – Responsibilities of Medicare Participating Hospitals SENIOR SERVICES in Emergency Cases (Rev. 1, 05-21-04); (C) Shall be maintained as the first page of a patient’s medical record in a health care facility unless otherwise specified in the health care facility’s policies and procedures; (D) Shall be transferred with the patient when the patient is transferred from one health care facility to another health care facility; (E) Shall be provided to any other facility, person, or agency responsible for the medical care of the patient or to the patient or patient’s representative if the patient is transferred outside of a hospital; (F) Shall be signed and dated by the patient or the patient’s legal representative and the patient’s attending physician. A patient’s attending physician may electronically sign his/her name to the OHDNR order form. A patient under the age of eighteen (18) years shall not sign and date an OHDNR order form for himself or herself. A patient under the age of eighteen (18) years may have an OHDNR order signed by at least one (1) parent, by at least one (1) of the patient’s legal guardian(s), or by a juvenile or family court under the provisions of section 191.250, RSMo, if the patient is under juvenile court jurisdiction under section 211.031, RSMo; (G) Shall be printed on eight and one half inch by eleven inch (8.5" × 11") card stock that is purple in color; (H) May be photocopied, faxed, or saved as an electronic copy, and this photocopy, electronic copy, or other complete facsimile of the original OHDNR order may be used for any purpose for which the original OHDNR order may be used; (I) May be revoked at any time by a patient or a patient’s representative. If a patient is under the age of eighteen (18), an OHDNR order may be revoked by the patient under the age of eighteen (18), by either parent, by the patient’s legal guardian, or by a juvenile or family court under the provisions of section 191.250, RSMo, if the patient is under juvenile court jurisdiction under section 211.031, RSMo. An OHDNR order may be revoked by— 1. Signing in the box on the OHDNR order form labeled revocation provision. The revocation provision box shall remain unsigned in order for the OHDNR order to remain in effect; 2. Expressing to emergency medical services personnel in any manner, before or after the onset of a cardiac or respiratory arrest, the desire to be resuscitated; or 3. Destroying a patient’s original OHDNR order form and any applicable OHDNR identification such as an identification card, bracelet, or necklace; and (J) Shall be valid and effective whether or not an instruction form is included on the back side of the OHDNR form or attached as a separate page to the OHDNR order form. (3) Emergency medical services personnel are authorized to comply with the OHDNR protocol when presented with OHDNR identification or an OHDNR order meeting the requirements in section (2) above. The department also authorizes emergency medical services personnel to comply with the OHDNR protocol when presented with the following forms that do not have to be purple in color, which are in compliance with the provisions of sections 190.600 to 190.621, RSMo, and are included herein— (A) Alaska Physician Orders for Life Sustaining Treatment (POLST) Form—Emergency medical services personnel and anyone listed in section 190.606, RSMo, as immune from liability are only authorized to comply with the specific do-notresuscitate section in Alaska’s POLST Form; (B) State of Arkansas Emergency Medical Services Do-NotResuscitate Order; (C) Georgia Physician Orders for Life-Sustaining Treatment (POLST) Form—Emergency medical services personnel and anyone listed in section 190.606, RSMo, as immune from liability are only authorized to comply with the specific do-notresuscitate section in Georgia’s POLST Form; (D) State of Indiana Out of Hospital Do-Not-Resuscitate Declaration and Order Form; (E) New Mexico Emergency Medical Services (EMS) Do-NotResuscitate (DNR) Form; (F) Kansas–Missouri Transportable Physician Orders for Patient Preferences (TPOPP/POLST)—This form shall be signed in compliance with Missouri law by the patient’s attending physician as defined in subsection (1)(A) above and the patient defined in subsection (1)(J) above or the patient’s representative in subsection (1)(K) above. Emergency medical services personnel and anyone listed in section 190.606, RSMo, as immune from liability are only authorized to comply with the specific do-not-resuscitate section in the Kansas-Missouri TPOPP/POLST as long as the physician and patient or patient’s representative have signed the form in accordance with Missouri law. (4) The OHDNR protocol includes the following standardized methods or procedures: (A) An OHDNR order shall only be effective when the patient has not been admitted to or is not being treated within a hospital or has not yet come to the emergency department as defined in the Emergency Medical Treatment and Active Labor Act (EMTALA), 42 U.S.C. section 1395dd, and the regulation 42 CFR section 489.24(a) and referenced in the Centers for Medicare & Medicaid Services State Operations Manual Appendix V—Interpretive Guideline—Responsibilities of Medicare Participating Hospitals in Emergency Cases (Rev. 191, 07-19-19); (B) Emergency medical services personnel shall not comply with an OHDNR order or the OHDNR protocol when the patient or patient’s representative expresses to such personnel in any manner, before or after the onset of a cardiac or respiratory arrest, the desire to be resuscitated; (C) Emergency medical services personnel shall not comply with an OHDNR order or the OHDNR protocol when the patient under eighteen (18) years of age, either parent of such patient, the patient’s legal guardian, or the juvenile or family court if the patient is under juvenile court jurisdiction under section 211.031, RSMo, expresses to such personnel in any manner, before or after the onset of a cardiac or respiratory arrest, the desire for the patient to be resuscitated; (D) An OHDNR order shall not be effective during such time as the patient is pregnant; (E) A properly executed OHDNR order authorizes emergency medical services personnel to withhold or withdraw cardiopulmonary resuscitation from the patient in the event of cardiac or respiratory arrest. Emergency medical services personnel shall not withhold or withdraw other medical interventions, such as intravenous fluids, oxygen, or therapies other than cardiopulmonary resuscitation such as those to provide comfort care or alleviate pain. Nothing in this regulation shall prejudice any other lawful directives concerning such medical interventions and therapies; (F) If any doubt exists about the validity of the OHDNR identification or an OHDNR order, resuscitation shall be initiated and medical control shall be contacted; (G) If the OHDNR order or OHDNR identification is presented after basic or advanced life support procedures have started, the emergency medical services personnel shall honor the form and withhold or withdraw cardiopulmonary resuscitation from a patient who is suffering cardiac or respiratory arrest; (H) After noting the properly executed OHDNR order or OHDNR identification, no cardiac monitoring is necessary and no medical control contact is necessary; and (I) Emergency medical services personnel shall document review of the OHDNR order and/or OHDNR identification in the patient care record. (5) Single Color, Form, and Design for Additional/Optional OHDNR Identification. (A) The OHDNR identification card— 1. Shall be signed and dated by the patient or the patient’s legal representative and the patient’s attending physician; 2. Shall be printed on card stock that is purple in color; and 3. Shall be three and seven-sixteenths by four and one- eighth (3 7/16 × 4 1/8) inches in size and may be folded and/or laminated. (B) The OHDNR bracelet— 1. Shall contain a representation of the geographical shape of Missouri with the word “STOP” etched in purple, imposed over the geographical shape of Missouri on the face of the bracelet; and 2. Shall contain the inscription “MO OHDNR order” on the back of the bracelet. (C) The OHDNR necklace— 1. Shall include a medallion containing a representation of the geographical shape of Missouri with the word “STOP” etched in purple, imposed over the geographical shape of Missouri on the face of the medallion; and 2. Shall contain the inscription “MO OHDNR order” on the back of the medallion. (D) OHDNR bracelet and necklace vendors shall obtain approval from the department prior to manufacturing and distributing an initial OHDNR bracelet and necklace for a Missouri resident. To obtain approval from the department, OHDNR bracelet and necklace vendors shall submit to the department— 1. A document expressing an interest in manufacturing and distributing OHDNR bracelets and necklaces for Missouri residents; 2. A document stating that the OHDNR vendor understands and agrees to manufacture and distribute the OHDNR bracelet and necklace for each patient only after being shown an OHDNR order issued by the patient’s attending physician for the patient requesting the OHDNR bracelet or necklace. This OHDNR order must be executed by the patient or patient’s representative and the patient’s attending physician and on the form created by the department, included herein; 3. A document stating that the OHDNR vendor understands and agrees to send with the OHDNR bracelet or necklace a statement with the words, “Pursuant to sections 190.600– 190.621, RSMo, this OHDNR identification shall only be worn by a person who has executed an effective OHDNR order”; and 4. A prototype of the necklace and/or bracelet that meets the specifications as described herein in subsection (5)(B) or (5) (C). (E) After review of the required documentation and prototype from an OHDNR vendor, the department may approve the OHDNR vendor to manufacture and distribute OHDNR bracelets and necklaces. A list of approved OHDNR bracelet or necklace vendors is available at the EMS Bureau office, online at www. dhss.mo.gov/EMS or may be obtained by mailing a written request to the Missouri Department of Health and Senior Services, EMS Bureau, PO Box 570, Jefferson City, MO 651020570. (F) Department-approved OHDNR vendors shall be shown, for each patient requesting an OHDNR bracelet or necklace, an effective OHDNR order issued by the patient’s attending physician for the patient requesting the OHDNR bracelet or necklace. To be effective, this OHDNR order must be executed by the patient or patient’s representative and the patient’s attending physician and on the form created by the department, included herein. (G) Department-approved OHDNR vendors shall send with each OHDNR necklace or bracelet manufactured and distributed to a Missouri resident a statement with the words, “Pursuant to sections 190.600–190.621, RSMo, this OHDNR identification shall only be worn by a person who has executed an effective OHDNR order.” Next Section Next Section