Start with your care team
A DNR addresses resuscitation. POLST/MOLST forms can address additional treatment choices. The applicable form, authorized practitioner, consent process and recognition depend on the state and care setting. Discuss what the choices mean for the patient before completing an order.
- Choose the state and whether you need an out-of-hospital, hospital, pediatric or POLST workflow.
- Discuss the patient’s wishes, condition and decisionmaking capacity with the treating clinician. If someone acts for the patient, verify that person’s authority for the decision.
- Use the applicable form and clinical process. For in-hospital care, ask the facility to enter the order. Pediatric decisions need the relevant consent and clinical review.
- Ask how to communicate, keep, review and change the order, and what happens when the patient moves between care settings.
Communicating a change
Identify the existing order, where the patient is receiving care and who is communicating. Tell the treating team directly about the patient's current wishes. For a District of Columbia MOST, the patient or authorized representative can communicate intent orally to treating EMS or a treating health professional. For a New Jersey POLST, ask the attending physician, PA or APN to sign the order attesting to the request. A New Jersey representative seeking a change after the patient loses capacity must have authorization on the POLST and consult the attending physician or APN. A separate out-of-hospital DNR has its own process.
Forms and program instructions
D.C. Medical Orders for Scope of Treatment ↗
District of Columbia portable order, clinician registration and instructions.
New Jersey POLST ↗
Department of Health POLST form for care across settings.
New Jersey out-of-hospital DNR ↗
Community DNR order and EMS instructions for the care team.
New York nonhospital DNR — DOH-3474 ↗
Complete with the authorized clinician using the Department of Health consent and capacity procedures.
New York MOLST program ↗
DOH-5003 and the applicable legal-requirements checklists, including special consent procedures.
California POLST forms ↗
EMSA-approved form, patient information and clinician instructions from the state program.
Texas out-of-hospital DNR program ↗
DSHS form and instructions for the required signing process.
State and DC POLST program directory ↗
Locate your state program. For DNR procedures, also ask the treating clinician or local EMS authority.
Planning guide
Our sample explains the next steps and links to clinical resources. It is not a medical order, has no clinician signature block, and must not be presented to emergency responders as a DNR.
Changing a New York order
Tell the treating team which instruction you want to discuss. A nonhospital DNR addresses CPR. A MOLST can contain separate treatment orders. Identify who gave consent, what the patient wants now and who has heard the request. Creating a communication record does not notify the care team.
New York nonhospital DNR procedures · Revocation under the Family Health Care Decisions Act · New York MOLST questions and answers
Start a New York communication record