Advance Directives

Yes – Facilities may modify the form's background and add handwritten information to the form. First and foremost, the DNAR order authentication time should be handwritten after the physician's signature, especially in hospital settings, where this is a CMS requirement. In addition, many have commented that the physician's license number (or other identifier) should be added under the physician's name to better distinguish the person signing the form from others with the same or similar name. Nevertheless, a signed and dated form, even without the time of signature, can be accepted as a valid DNAR form by a receiving hospital.

The form may be individualized with a facility or corporate logo; a bar code or other patient identifier may be added. The form is valid if printed on one page front and back or on two separate pages; it is valid if electronically reproduced or if copied on colored paper. It is not necessary for the ADPH seal as a watermark to appear in the background for the form to be valid.

However, the exact wording of the form itself may not be changed at all unless it gets formal approval from the Committee of Public Health.

The Alabama State Advisory Council on Palliative Care and Quality of Life recommends that every institution and agency adopt the color PINK for the portable DNAR form.

This section is to some extent complex and has two subdivisions. The signature which follows this section must be placed by someone who is authorized to attest:

First, that the "..patient/resident is not competent or is no longer able to understand, appreciate, and direct his/her medical treatment and has no hope of regaining that ability."

Secondly: "A duly executed Advance Directive for Health Care with instructions that no life-sustaining treatment be provided was previously authorized by the patient/resident and is part of his/her medical record." It is not necessary that this section be signed by a physician. A person, such as a licensed administrator, a social worker, a PA or CRNP, a nurse, or other facility representative who is authorized to review the medical record and attest to the documentation in the medical record, could sign that these statements are true and correct. In the setting of use of this form by a patient at home for whom a close family member is the only person available to sign the form, the proper certification would be for that family member to sign Section 4 and have his/her signature on a signed and notarized Surrogate Decision Maker Form attached or incorporated in the medical record.

This act does not specifically mandate the acceptance of a valid DNAR form as an order in the facility receiving a patient/resident from another facility. The rule requires the sending facility to transmit the DNAR form and the receiving facility to incorporate it into the medical record. The statute does require that any facility or physician who objects to accepting a patient who has chosen to be a DNAR patient assist that person and family in finding an acceptable alternative care location where the patient's wishes can be followed.

In addition, the Natural Death Act and the federal Patient Self Determination Act (PL 101-508) have established a legal basis for the right of a patient/resident to direct his/her own health care including withholding or withdrawing life sustaining treatments. Suppose a patient/resident arrives with a valid Portable Physician DNAR form and experiences cardiopulmonary cessation immediately or very soon after arrival at the new location. Further, this person is subjected to CPR before an internal assessment, and the paperwork for a facility-specific DNR order can be completed. There could be adverse legal action against the receiving facility based on the recent passage of these amendments and the knowledge of and receipt of a valid Portable Physician DNAR Order form.

The acceptance of a valid Portable Physician DNAR Order form is not a part of any facility rule and will not be specifically investigated during the survey process. Nevertheless, failure by staff at any federally certified health care facility to document and follow the resident's wishes regarding CPR in the event of cardiopulmonary cessation will be investigated and enforced exactly as currently stipulated by CMS regulations

The Board of Medical Examiners has exclusive authority to adopt rules relating to physicians in implementing the act as amended. To date, the BME has taken no action in this regard.