1. Ambulance personnel in Maryland only recognize a DNR order when it is:
1. executed on a form issued by the Maryland Institute for Emergency Medical Services Systems (MIEMSS), and
2. signed by a Maryland-licensed physician or Nurse Practitioner.¹²

(See sample EMS/DNR Order form at Attachment L.) Ambulance personnel will not recognize as a valid EMS/DNR Order a statement in an Advance Directive, an Instructions on Current Life-Sustaining Treatment Options Form, or any other document.

2. Action

When a Resident or the Resident's Agent or surrogate has made an informed decision against efforts at resuscitation, or the Resident's physician or Nurse Practitioner has entered a DNR order, you must also:

1. complete the MIEMSS EMS/DNR Order, and
2. assure that the Resident's Maryland-licensed Attending Physician or Nurse Practitioner signs the MIEMSS EMS/DNR Order.

A sample form and corresponding instructions from MIEMSS are provided as Attachment L. Extra forms and a complete instruction manual can be obtained by calling the Attorney General of Maryland's MIEMSS Office at (410) 706-3666.

In the event that a Resident comes to this Facility with a valid MIEMSS EMS/DNR order or valid evidence of the order in bracelet or necklace form, the order will be copied or noted in the Resident's medical record and honored, unless or until the EMS/DNR order is revoked or replaced by a new physician's order addressing treatments related to cardio pulmonary arrest.

Prior to any cardiac or respiratory arrest of a Resident, Maryland law permits, but does not require, health care providers, including nursing facilities, to provide, withhold or withdraw treatment in accordance with a valid MIEMSS EMS/DNR order. As indicated on the MIEMSS EMS/DNR Form (Attachment L), the Resident or Agent may elect for "maximum efforts to prevent cardiac/respiratory arrest" or only "supportive care" prior to cardiac/respiratory arrest.

This Facility's policy is to honor the Resident's wishes in the MIEMSS EMS/DNR order as they pertain to care prior to cardiac/respiratory arrest, unless or until the MIEMSS EMS/DNR order is otherwise revoked or superseded by a subsequent physician's order.¹³ After a Resident’s cardiac or respiratory arrest, the Facility is required by law to withhold or withdraw treatment in accordance with the MIEMSS EMS/DNR order, unless or until it is otherwise revoked or superseded by a subsequent physician's order.