Clarification of DNR Orders Signed by Nurse Practitioners or Physician's Assistants

We have recently received several calls about the portable Do Not Resuscitate (DNR) order form, also known as the Goldenrod form. Several readers have told us that some physicians are under the impression that only a physician can sign a portable DNR order. This is incorrect. In 2004, the Office of Emergency Medical Services (OEMS) issued a memo in response to this same question and clarified that a physician’s assistant or nurse practitioner can also execute a portable DNR order, and the order is effective and “should be followed by all health care providers as if the orders were signed and issued by a physician.” The memo also stated that the official portable DNR form had been revised to reflect this interpretation.

Apparently, for reasons that are not clear, some providers have been told recently that this interpretation has changed. It has not. In response to an inquiry about this from several of us who work with end-of-life issues, OEMS on May 19, 2011, issued an updated memo clarifying and restating the substance of the 2004 memo—i.e., that portable DNR orders signed by a physician’s assistant or nurse practitioner are legal and should be honored just as if the physician with whom the PA or NP works had signed and issued the order, and that portable DNR orders signed by a PA or NP should be honored by all health care providers. The memo further states that this interpretation is based on an interpretation by the N.C. Medical Board, which regulates the practice of medicine in North Carolina.

Also, recall that the Medical Order for Scope of Treatment (MOST) form can also be signed by either a physician, nurse practitioner or physician’s assistant, and the MOST form specifically indicates this by designating the options of MD, PA or NP in the block where the medical provider must sign the form.

Please share this information with individuals in your facility who work with the DNR and/or MOST forms and with your medical director and other physicians who provide services in your facility. Please continue to share with us your questions about the portable DNR form, the MOST form or other end-of-life advance care planning issues, and we will continue to update our readers on these very important issues.