See 1999 Va. Acts ch. 814 (amended Mar. 29, 1999).Google Scholar

The term prehospital DNR, although common, is not used here because these protocols apply just as well at the posthospital stage and during transfers between health facilities.Google Scholar

See, for example, Scanlon, C. and Lomax, K., A Vision for Better Care at the End of Life: Five Principles of Palliative Care (Mar. 1999) (visited June 14, 1999) <http://www.lastacts.org/scripts/InfoWare.exe?FNC=PreceptsForUSers_Ala_info_launchpad_html>..>Google Scholar

See, for example, Larson, E.J. and Eaton, T.A., “The Limits of Advance Directives: A History and Assessment of the Patient Self-Determination Act,” Wake Forest Law Review, 32 (1997): 349–93.Google Scholar

See Iserson, K.V., “Forgoing Prehospital Care: Should Ambulance Staff Always Resuscitate?,” Journal of Medical Ethics, 17 (1991): 3–4; Koenig, K.L., “Do-Not-Resuscitate Orders. Where Are They In The Prehospital Setting?,” Prehospital Disaster Medicine, 8 (1993): 51–54; Partridge, R.A., “Field Experience with Prehospital Advance Directives,” Annals of Emergency Medicine, 32 (1998): 589–93 (survey of local emergency medical services (EMS) providers in Massachusetts and New Hampshire prior to the creation of statewide protocols.)Google Scholar

See American College of Emergency Physicians, “Guidelines ‘Do Not Resuscitate’ Orders in the Prehospital Setting,” Annals of Emergency Medicine, 17 (1998): 1106–08.CrossRefGoogle Scholar

See National Association of State Emergency Medical Services Directors and National Association of Emergency Medical Services Physicians, “National Guidelines for Statewide Implementation of EMS ‘Do Not Resuscitate’ (DNR) Programs,” Prehospital Disaster Medicine, 9 (1994): 137–39; and Association of Emergency Physicians, AEP Policy Statement on Prehospital Do Not Resuscitate Orders (visited June 2, 1999) <http://www.aep.org/policies.html>. The National Association of Emergency Medical Technicians (NAEMT) have all adopted positions or national guidelines in favor of EMS-DNR programs. See also Emergency Cardiac Care Committee and Subcommittees, American Heart Association, “Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiac Care, Part 8: Ethical Considerations in Resuscitation,” JAMA, 268 (1992): 2282–88..+The+National+Association+of+Emergency+Medical+Technicians+(NAEMT)+have+all+adopted+positions+or+national+guidelines+in+favor+of+EMS-DNR+programs.+See+also+Emergency+Cardiac+Care+Committee+and+Subcommittees,+American+Heart+Association,+“Guidelines+for+Cardiopulmonary+Resuscitation+and+Emergency+Cardiac+Care,+Part+8:+Ethical+Considerations+in+Resuscitation,”+JAMA,+268+(1992):+2282–88.>Google Scholar

See Horttor, B.J., “A Survey of Living Will and Advanced Health Care Directives,” North Dakota Law Review, 74 (1998): 233–93.Google Scholar

See Cruzan v. Director, Missouri Department of Health, 497 U.S. 261 (1990).Google Scholar

See, for example, Hamill, R.J., “Resuscitation: When is Enough, Enough?,” Respiratory Care, 40 (1995): 515–24; Lombardi, G. Gallagher, E.J., and Gennis, P., “Outcome of Out-of-Hospital Cardiac Arrest in New York City,” JAMA, 271 (1994): 678–83; Applebaum, G.E. King, J.E., and Finucane, T.E., “The Outcome of CPR Initiated in Nursing Homes,” Journal of the American Geriatric Society, 38 (1990): 197–200.Google Scholar

See, for example, Partridge, supra note 5; Hall, S.A., “An Analysis of Dilemmas Posed by Prehospital DNR Orders,” Journal of Emergency Medicine, 15 (1997): 109–11; Fitzgerald, D.J. Milzman, D.P., and Sulmasy, D.P., “Creating a Dignified Option: Ethical Considerations in the Formulation of Prehospital DNR Protocol,” American Journal of Emergency Medicine, 13 (1995): 223–28; and van Stralen, D., Editorial, “Do Not Resuscitate, But Do Not Forget Comfort,” American Journal of Emergency Medicine, 13 (1995): 93–9.4Google Scholar

See Sachs, G.A. Miles, S.H., and Levin, R.A., “Limiting Resuscitation: Emerging Policy in the Emergency Medical System,” Annals of Internal Medicine, 114 (1991): 151–54.CrossRefGoogle Scholar

See Adams, J.G., “Prehospital Do-Not-Resuscitate Orders: A Survey of State Policies in the United States,” Prehospital Disaster Medicine, 8 (1993): 317–22.Google Scholar

See Miles, S.H., “Orders to Limit Emergency Treatment for an Ambulance Service in a Large Metropolitan Area,” JAMA, 254 (1985): 525–27; see also Jezierski, M., “Minneapolis Prehospital Do-Not-Resuscitate Form Provides Model for Others,” Journal of Emergency Nursing, 14 (1988): 26A–29A.Google Scholar

The state contacts are identified in the state EMS-DNR Profiles on file with the author.Google Scholar

The organizations contacted for information were the National Association of State Emergency Medical Directors, the National Association of Emergency Medical Services Physicians, the American College of Emergency Physicians, NAEMT, the International Association of Fire Fighters, and the MedicAlert® Foundation.Google Scholar

See Alaska Stat. §§ 18.12.010–.100 (Michie 1998); Ariz. Rev. Stat. Ann. § 36–3251 (West 1999); Ark. Code Ann. §§ 20-13-901 to −911 (Michie 1997); Cal. Prob. Code § 4753 (West 1999); Colo. Rev. Stat. Ann. §§ 15–18.6–101 to −108 (West 1999); Conn. Gen. Stat. § 19a-580d (1998); Fla. Stat. Ann. § 401.45(3) (West 1999), but see §§ 395.1041(3), 400.142(3), 400.4255(3), 400.487(7), 400.6095(8), and 400.621(3) for its application to various health care providers; Ga. Code Ann. §§ 31-39-1 to −9 (1999); Haw. Rev. Stat. Ann. §§ 321–222, −229.5 (Michie 1998); Idaho Code §§ 39–150 to −165 (1998); Ind. Code Ann. §§ 16-36-5-1 to −24 (West 1999); Kan. Stat. Ann. §§ 65–4941 to −4949 (1997); Ky. Rev. Stat. Ann. § 311.623(3) (Banks-Baldwin 1999); La. Rev. Stat. Ann. §§ 40:1299.58.1–.10 (West 1999); Md. Code Ann., Health-Gen. §§ 5–601, −608, −617 (1998); Mich. Comp. Laws Ann. §§ 333.1051–.1067 (West 1998); Mont. Code Ann. §§ 50-10-101 to −106 (1997); Nev. Rev. Stat. §§ 450B.400–.490 (1997); N.H. Rev. Stat. Ann. § 151-B:18 (1998); N.M. Stat. Ann. § 24–10B-4(J) (Michie 1998); N.Y. Pub. Health Law §§ 2960–2978 (McKinney 1999); N.C. Gen. Stat. §§ 32A-15 to −26, 90–320 to −322 (1998) (applicable to DNR orders according to health, Op. Att'y Gen. 1997 WL 858260 (Dec. 22, 1997); Ohio Rev. Code Ann. §§ 2133.01–.26 (Banks-Baldwin 1999); Okla. Stat. Ann. tit. 63, §§ 3131.1–.14 (West 1999); R.I. Gen. Laws §§ 23–4.11–1–.14 (1998); S.C. Code Ann. §§44-78-10 to −65 (Law. Co-op. 1998); Tenn. Code Ann. §§ 68-140-601 to −604, 68-11-224 (1998); Tex. Health & Safety Code Ann. §§ 166.081–.101 (West 1999); Utah Code Ann. § 75-2-1105.5 (1998); Va. Code Ann. §§ 54.1–2987.1, −2988, −2989, −2982 (Michie 1999); Wash. Rev. Code Ann. § 43.70.480 (West 1998); W. Va. Code §§ 16–30C-1 to −16 (1998); Wis. Stat. Ann. §§ 154.19–.29 (West 1999); and Wyo. Stat. Ann. §§ 35-22-201 to −208 (Michie 1998).Google Scholar

See Ala. Admin. Code r. 420-2-1.02–.30 (1999); III. Admin. Code tit. 77, § 515.380 (1997); Maine Emergency Medical Services, “Do Not Resuscitate Guidelines and Comfort Care/DNR Form” (Sept. 1993); Massachusetts Office of Emergency Medical Services, “Comfort Care/Do Not Resuscitate Order Verification Protocol” (May 1997); Minnesota Medical Association, “Policy Compendium on Recommended ‘Do Not Resuscitate’ (DNR) Guidelines for Minnesota Emergency Medical Service Agencies” (1993); Mo. Code Regs. Ann. tit. 19, §§ 30–40.303(1)(B), (2)(B) (1999); Medical Society of New Jersey, “Guidelines for Physicians and Policy for Emergency Medical Services Personnel Concerning ‘Do Not Resuscitate’ (DNR) Orders for Patients Located Outside of a Hospital or Long Term Care Facility” (undated); and Or. Admin. R. 847-035-0030(7) (1998).Google Scholar

These include Delaware, District of Columbia, Iowa, Mississippi, Nebraska, North Dakota, Pennsylvania, South Dakota, and Vermont.Google Scholar

For more information about Physician Orders for Life-Sustaining Treatment, see Midwest Bioethics Center, “Implementing End-of-Life Treatment Preferences Across Clinical Settings,” State Initiatives in End-of-Life Care, 3 (Apr. 1999) (one of a limited series of practice briefs published by Community-State Partnerships to Improve End-of-Life Care and Last Acts, a national program supported by the Robert Wood Johnson Foundation).Google Scholar

See N.Y. Pub. Health Law § 2961(3) (McKinney 1999).Google Scholar

Most states permit consent to an EMS-DNR order by an appointed agent, family member, or guardian where the patient lacks capacity, although significant variation exists. See Table 3.Google Scholar

Kentucky permits notarization in lieu of witnessing. It incorporates the same formalities required of living will directives. See Ky. Rev. Stat. Ann. § 311.625(2) (Michie 1997).Google Scholar

They include Alabama, Nevada, New Hampshire, Rhode Island, and Wyoming. In Louisiana, an individual must complete a health care declaration (living will) and register it with the secretary of state to receive a DNR identification bracelet.Google Scholar

They include Illinois, Michigan, Minnesota, Missouri, North Carolina, Oklahoma, Oregon, South Carolina, and Tennessee.Google Scholar

They include Alabama, Connecticut, Georgia, Louisiana, New Hampshire, Rhode Island, and Wisconsin.Google Scholar

They are permissible in Arkansas, California, Indiana, Kansas, Maryland, New Mexico, and West Virginia.Google Scholar

They include Alaska, Arizona, Maryland, Montana, Nevada, and Ohio.Google Scholar

Indiana and Louisiana are not listed because their 1999 statutes have not yet been fully implemented.Google Scholar

See, for example, Schneiderman, L.J., “Medical Futility and Aging: Ethical Implications,” Generations, 18 (1994): 61–65; and compare Scofield, G.R., “Medical Futility: Can We Talk?,” Generations, 18 (1994): 66–70.Google Scholar

Missouri could be added to each of these three sums, but it is not included here. Although it recognizes consent by an “appropriate surrogate,” no description of the term's meaning could be found.Google Scholar

They include Alaska, Arizona, Arkansas, California, Colorado, Florida, Georgia, Hawaii, Idaho, Indiana, Kansas, Kentucky, Louisiana, Maryland, Michigan, Montana, Nevada, New York, Ohio, Oklahoma, Rhode Island, South Carolina, Tennessee, Texas, Utah, Virginia, West Virginia, Wisconsin, and Wyoming.Google Scholar

See Conn. Gen. Stat. § 52–557b (West 1998) (Good Samaritan Law); N.H. Rev. Stat. Ann. § 151-B:16 (1999) (EMS statute); N.M. Stat. Ann. § 24–10B-8 (1997) (EMS statute); and Wash. Rev. Code Ann. § 18.71–210 (West 1997) (EMS statute).Google Scholar

See N.C. Gen. Stat. § 90–21.14(b) (1998) (Good Samaritan Law protects volunteers but not EMS personnel who provide services in the normal course of business); N.C. Gen. Stat. § 20–166(d) (1998) (immunity for any person who renders first aid or emergency assistance at the scene of a motor vehicle accident).Google Scholar

They include Alaska, Arkansas, Colorado, Georgia, Indiana, Kansas, Kentucky, Louisiana, Montana, Nevada, New York, Ohio, Oklahoma, Rhode Island, Texas, Utah, Virginia, West Virginia, Wisconsin, and Wyoming.Google Scholar

They include Ky. Rev. Stat. Ann. § 311.635 (Banks-Baldwin 1999); Md. Code Ann., Health-Gen. § 5–609(b) (1998); N.Y. Pub. Health Law § 2974(3) (McKinney 1999); Utah Code Ann. § 75-2-1114 (1998); and Va. Code Ann. § 54.1–2988 (Michie 1998).Google Scholar

See Nev. Rev. Stat. § 450B.540(2) (1997).Google Scholar

See Ariz. Rev. Stat. Ann. § 36–3251(J) (West 1998).Google Scholar

Alabama, Illinois, Maine, Massachusetts, Missouri, New Jersey, and Oregon rely on general or partial immunity in other parts of their EMS code coupled with the recognition of the EMS protocol as part of the standard of practice. See Ala. Code § 6-5-332 (1998); 50 Ill. Comp. Stat. 3.150 (West 1998); Me. Rev. Stat. Ann. tit. 32, § 93-A (West 1998); Mass. Gen. Laws Ann. ch. 111C, §§ 13–14 (West 1999); Mo. Ann. Stat. § 190.092 (West 1999); N.J. Stat. Ann. §§ 26:2K-14, −29, −38 (West 1999); and Or. Rev. Stat. § 431.617 (1998). Minnesota does not have a general immunity provision for health care providers in its state code. See Minn. Stat. Ann. §§ 604A.01–.015 (West 1998) (Good Samaritan immunity only applies to volunteers and school bus drivers).Google Scholar

Ohio Rev. Code Ann. § 2133.21(G) (Banks-Baldwin 1998).Google Scholar

Colo. Rev. Stat. Ann. § 15–18.6–101(1) (West 1997) (emphasis added).Google Scholar

They include Michigan, Tennessee, West Virginia, and possibly Hawaii.Google Scholar

They are Texas and possibly Hawaii.Google Scholar

“Neither the provider, the ambulance service, nor any other person or entity shall be liable for attempting to resuscitate against the patient's will.” Haw. Rev. Stat. Ann. § 321–229.5(b)(3) (Michie 1997).Google Scholar

They include Arizona, California, Colorado, Indiana, Kansas, Kentucky, Maryland, New York, Oklahoma, South Carolina, Texas, Utah, West Virginia, and Wyoming.Google Scholar

They include Alaska, Arizona, Indiana, New York, and Ohio. Alabama is not included here because its regulatory immunity provision applies only to disciplinary actions.Google Scholar

They are Arizona, Indiana, and New York.Google Scholar

The provider must have no “knowledge that the action or decision would be inconsistent with a health care decision that the individual signing the request would have made on his or her own behalf under like circumstances.” Cal. Prob. Code § 4753(a) (West 1999).Google Scholar

They include Arkansas, Florida, Georgia, Hawaii, Idaho, Louisiana, Michigan, Montana, Nevada, Rhode Island, Tennessee, Virginia, and Wisconsin.Google Scholar

See Ala. Admin. Code r. 420-2-1.20 (1999).Google Scholar

See, for example, Idaho Code § 39.159(1)(d) (1998) (no liability for providing “life-sustaining procedures pursuant to an oral or written revocation…”).Google Scholar

See, for example, Ga. Code Ann. § 31-39-7(b)(1) (1998) (“…reasonably and in good faith was unaware of the issuance of an order not to resuscitate…”).Google Scholar

See Haw. Rev. Stat. Ann. § 321.299.5(b)(3) (Michie 1997) (“the provider's safety, the safety of the family or immediate bystanders…”); Idaho Code § 39–157 (1998) (“to avoid verbal or physical confrontation…”); and N.Y. Pub. Health Law § 2977(10) (McKinney 1999) (“family members or others on the scene … object to the order and physical confrontation appears likely…”).Google Scholar

See, for example, S.C. Code Ann. § 44-78-35(4) (Law Co-op. 1998) (no liability for providing CPR if “the care was necessary to relieve pain or suffering or to provide comfort care to the patient.”).Google Scholar

See, for example, Idaho Code § 39–164 (1998) (“This act does not apply to situations involving mass casualties.”).Google Scholar

See, for example, Ariz. Rev. Stat. Ann. § 36–3205 (West 1998) (no liability for unwillingness to comply with a DNR order “that violates the provider's conscience if the provider promptly makes known the provider's unwillingness and promptly transfers the responsibility for the patient's care to another provider who is willing…”).Google Scholar

See Ala. Admin. Code r. 420-2-1.20 (1999) (“EMS may withhold resuscitative measures…”); Fla. Stat. Ann. § 401.45(3)(a) (West 1999) (“Resuscitation may be withheld or withdrawn from a patient by an emergency medical technician or paramedic…”); and Tenn. Code Ann. § 68-140-602 (1998) (EMS “may honor a DNR order…”) (emphases added).Google Scholar

See Rhode Island Department of Health, Emergency Medical Services, Run Reports marked with Comfort One Protocol (unpublished) (data as of Oct. 31, 1998, provided by Peter Leary, Chief, Emergency Medical Services Division, Rhode Island).Google Scholar

They include Florida, Massachusetts, Oregon, Utah, West Virginia, and Wisconsin. The Kansas City area of Kansas also keeps cumulative numbers but the rest of the state does not.Google Scholar

They include Alaska, Hawaii, Montana, Utah, and Wyoming. (Note that Utah tracks both the aggregate numbers of forms sent out and the enrollees.)Google Scholar

See, for example, Kendellen, R.M., “Rescue Squads and ‘Do Not Resuscitate’ Orders,” New Jersey Law Journal, 150 (1997): 998–1000; Rikook, J.J., “Do Not Resuscitate Orders: The New York Statutory Model—Part I,” Medical Staff Counselor, 5 (1991): 23–31; Rikook, J.J., “Do Not Resuscitate Orders: The New York Statutory Model—Part II,” Medical Staff Counselor, 6 (1992): 15–26; and Iserson, K.V., “A Simplified Prehospital Advance Directive Law: Arizona's Approach,” Annals of Emergency Medicine, 22 (1993): 1703–10.Google Scholar

See Sosna, D.P., “Implementation Strategies for a Do-Not-Resuscitate Program in the Prehospital Setting,” Annals of Emergency Medicine, 23 (1994): 1042–46.Google Scholar

See Sosna, D.P., “Advance Directives for Emergency Medical Services Workers: The Struggle Continues,” Bioethics Forum, 14 (Spring 1998): 33–36.Google Scholar

See Travers, D.A. and Mears, G., “Physicians' Experience with Prehospital Do-Not-Resuscitate Orders in North Carolina,” Prehospital and Disaster Medicine, 11 (1996): 91–100.Google Scholar

See Bentley, R., Reviving the “Do Not Resuscitate” Issue: An Examination of Survey Results (1998) (unpublished, prepared for the Oklahoma Association for Healthcare Ethics, Inc. and the Aging Services Division, Oklahoma Department of Human Resources). The response rate and sampling methodology are not described in the report.Google Scholar

See Dunn, P.M., “A Method to Communicate Patient Preferences about Medically Indicated Life-Sustaining Treatment in the Out-of-Hospital Setting,” Journal of the American Geriatric Society, 44 (1996): 785–91.CrossRefGoogle Scholar

See Tolle, S.W., “A Prospective Study of the Efficacy of the Physician Order Form for Life-Sustaining Treatment,” Journal of the American Geriatric Society, 46 (1998): 1097–102.Google Scholar

They include Arkansas, Colorado, Illinois, Maine, Massachusetts, Mississippi, Montana, Nevada, New Hampshire, Ohio, Oregon, South Carolina, Utah, Virginia, Wisconsin, and Wyoming.Google Scholar

They include Arizona, Colorado, Florida, Kansas, Nevada, New Mexico, Oregon, Texas, and Virginia.Google Scholar

They were identified in Colorado, Michigan, Minnesota, Nevada, New Hampshire, New Jersey, Washington, and West Virginia.Google Scholar

This was noted in Alabama, Connecticut, Florida, Maryland, Utah, Virginia, Washington, and Wisconsin.Google Scholar

They were reported in Hawaii, Oklahoma, Tennessee, and Washington.Google Scholar

This arose in Oregon, Utah, Virginia, and Washington.Google Scholar

Good examples include: Colorado at <http://www.state.co.us/gov_dir/cdphe_dir/em/cprdhom.htm>; Maryland at <http://miemss.umab.edu/progdev.htm>; Massachusetts at <http://www.state.ma.us/dph/oems/ccare.htm>; Boston area EMS at <http://www.mbemsc.org/provider/cc-dnr.htm>; and Oregon at <http://www.ohsu.edu/ethics/polst.htm>.;+Maryland+at+;+Massachusetts+at+;+Boston+area+EMS+at+;+and+Oregon+at+.>Google Scholar

The survey did not systematically review revocation provisions, hence the tables include no breakdown or tally of revocation provisions.Google Scholar

6 Colo. Code Regs. § 1015-2-3.5(c) (1998) (“Rules Pertaining to Implementation and Application of Advance Medical Directives for Cardiopulmonary Resuscitation (CPR) By Emergency Medical Service Personnel”).Google Scholar

See supra note 53 for states with a safety exception.Google Scholar

See Rhode Island Department of Health, supra note 58.Google Scholar

See Sachs, Miles, , and Levin, supra note 12, at 153.Google Scholar