Iowa Code agency 641, ch. 142, app A - [Effective 6/1/2025] Iowa Department of Health and Human Services

Iowa Department of Public Health

OUT-OF-HOSPITAL DO-NOT-RESUSCITATE ORDER

(Please type or print)

Date of Order: _____/_____/_____

Patient Information:

Name: (Last)____________________(First)____________________(Middle)__________________

Address: _____________________________(City)___________________(Zip)____________

Date of Birth: _____/_____/_____ Gender (Circle): M or F

Name of Hospice or Care Facility (if applicable): _________________________________________

______________________________________________________________________________

Attending Physician or Physician Assistant Order

As the attending physician or attending physician assistant for the above-named patient, I certify that this individual is over 18 years of age and has a terminal diagnosis. After consultation with this patient (or the patient's legal representative), I hereby direct any and all health care providers, including qualified emergency medical services (EMS) personnel, to withhold or withdraw the following life-sustaining procedures in accordance with Iowa law (Iowa Code chapter 142A):

* Cardiopulmonary Resuscitation/Cardiac Compression (Chest Compressions).

* Endotracheal Intubation/Artificial or Mechanical Ventilation (Advance Airway Management).

* Defibrillation and Related Procedures.

* Use of Resuscitation Drugs.

This directive does NOT apply to other medical interventions for comfort care.

	______/______/______
Signature of Attending Physician (MD, DO) or Attending Physician Assistant	Date
	(______)_____-_______
Printed Name of Attending Physician or Attending Physician Assistant	Physician's or Physician Assistant's Telephone (Emergency)

To the extent that it is possible, a person designated by the patient may revoke this order on the patient's behalf. If the patient wishes to authorize any other person(s) to revoke this order, the patient MUST list those persons' names below:

Name: _______________________________

Name: _______________________________

Name: _______________________________

Name: _______________________________

Patients, please note: Directions for obtaining a uniform identifier are listed on the back of this form. The uniform identifier is the key way the health care provider and/or EMS personnel can quickly recognize that you have an Out-of-Hospital Do-Not-Resuscitate order. If you are not wearing an identifier, the health care provider and/or EMS personnel may not realize that you do not want to be resuscitated.

Physicians or physician assistants, please note: Information regarding the completion of an Out-of-Hospital Do-Not-Resuscitate order is on the back of this form.

Directions for obtaining a uniform identifier:

The uniform identifier may be obtained through MedicAlert®1, which requires:

1. A completed MedicAlert® application, which is available in physician or physician assistant offices or through MedicAlert® by phoning (800)432-5378 or the website www.medicalert.org, and fee.

2. A copy of this completed OOH DNR order, which must accompany the MedicAlert® application or be sent to MedicAlert® prior to the identifier's being mailed.

Suggested guidelines for physicians or physician assistants:

1. Please review the Iowa Out-of-Hospital Do-Not-Resuscitate order and related protocol with the patient/patient's legal representative(s). The following points may be helpful:

* Patient/patient's legal representative(s) listed on this order must understand the significance of this order, that in the event the patient's heart or breathing stops or malfunctions, the anticipated result of this order is death.

* Patient/patient's legal representative(s) listed on this order may revoke this directive at any time. However, the desire to revoke must be communicated to the EMS or other health care professionals at the scene.

* It is important to emphasize that this order does not apply to medical interventions to make the patient more comfortable.

* The importance of wearing the uniform identifier for those qualified patients who would benefit from the mobility this offers should be stressed. It is also helpful to walk patients through the process they must follow to acquire the identifier.

2. Provide a copy of this order to the patient/patient's legal representative(s) listed on this order and place the original in the patient's medical records.

The OOH DNR Order form is available through the Iowa Department of Public Health, Bureau of EMS, Lucas State Office Building, Des Moines, Iowa 50319-0075, or through the Bureau of EMS's website idph.iowa.gov/BETS/EMS/rules.

Notes

Iowa Code agency 641, ch. 142, app A

ARC 7550B, IAB 2/11/09, effective 3/18/09

Adopted by IAB April 2, 2025/Volume XLVII, Number 20, effective 6/1/2025

MedicAlert® is a nonprofit 501C membership organization.