The Connecticut DNR transfer form is a one-page medical order that travels with a patient moving between healthcare facilities, directing staff and EMS providers not to perform CPR. It documents that a valid do-not-resuscitate order already exists at the sending institution and ensures that order follows the patient into transport and into the next setting.
Where to Get the Form
You can download the form directly from the Connecticut Department of Public Health website under the “Healthcare” section of its forms page, or request a copy from the administrative office of the patient’s current care facility.1Connecticut Department of Public Health. Forms The current version is dated December 2023.2State of Connecticut Department of Public Health. Connecticut Department of Public Health DNR Transfer Form
What Goes on the Form
The form is short. Four fields of patient and institutional information sit at the top, followed by a signature block for the signing clinician.2State of Connecticut Department of Public Health. Connecticut Department of Public Health DNR Transfer Form
- Patient’s name, entered exactly as it appears in the medical record.
- Transferring institution, meaning the facility the patient is leaving.
- Original DNR order date, taken from when the order was entered in the patient’s chart.
- Original DNR ordered by, with a checkbox for physician or APRN.
The signature block asks for a printed name, signature, title (physician, APRN, or registered nurse), and the date signed. The form does not ask for the patient’s date of birth, the name of the receiving facility, or any description of the patient’s medical condition. Keep every entry legible. A form that EMS personnel cannot read during an emergency creates exactly the confusion it was designed to prevent.
Who Can Sign the Form
Connecticut regulation 19a-580d-2 recognizes a DNR transfer form signed by a licensed physician or a registered nurse.3Connecticut eRegulations. Regulations of Connecticut State Agencies – Recognition and Transfer of Do Not Resuscitate Orders – Section 19a-580d-2 DNR Transfer Form The form itself elaborates: a physician or APRN who wrote the original order can sign, and a registered nurse can also sign by attesting that a valid DNR order exists in the patient’s medical record at the transferring institution.2State of Connecticut Department of Public Health. Connecticut Department of Public Health DNR Transfer Form
An RN on the floor can sign the transfer form. Advanced practice credentials are not required, because the nurse is attesting to an existing order rather than writing a new one. Physician assistants are not listed on the form or in the regulation as authorized signers. Once signed, the document becomes a formal medical order that protects clinicians who follow its instructions during transport and at the receiving facility.
Who Can Request the Transfer
An adult patient with capacity to make their own medical decisions can request the DNR transfer. When the patient cannot communicate or has lost decision-making capacity, an authorized health care representative steps in.4Connecticut General Assembly. Connecticut Code Chapter 368w – Removal of Life Support Systems and Medical Orders for Life-Sustaining Treatment The statute authorizing DNR orders identifies “the patient or his or her authorized representative” as the parties who can request and use the DNR system, and requires the physician or APRN who issued the original DNR order to assist them in the process.5Justia. Connecticut Code 19a-580d – Do Not Resuscitate Orders Definition Regulations
How the Form Travels During a Transfer
The regulation governing transfers is specific about who shows the form to whom and when. A legible copy carries the same weight as the original; the regulation consistently refers to “the DNR transfer form or a legible copy.”6Connecticut eRegulations. Regulations of Connecticut State Agencies 19a-580d-3 – Transfer and Recognition of DNR Orders When Patients Are Transported
- At the sending facility, the staff person who transfers care to EMS shows them the DNR transfer form, a legible copy, or a DNR bracelet.
- During transport, EMS providers keep the form accessible.
- At the receiving facility, the EMS provider shows the form to a nurse or physician. If neither is immediately available, the person in charge of patient care receives it.
- After arrival, the form or copy is retained with the patient’s medical record at the new facility.
The duty to show the form sits with facility staff at departure and with EMS at arrival, not with the family. Even so, keeping a copy and knowing the handoff reduces the chance of a gap. If no DNR form or bracelet is present when an emergency occurs, EMS providers default to performing resuscitation.
When a Bracelet or MOLST Applies Instead
The transfer form is designed for facility-to-facility moves. For a patient living at home or elsewhere in the community, the DNR bracelet is the recognized indicator EMS providers are trained to look for; a necklace is not recognized in Connecticut.7Connecticut eRegulations. Regulations of Connecticut State Agencies 19a-580d-4 – DNR Bracelets The bracelet is supplied through the agency designated by DPH, currently the Connecticut College of Emergency Physicians, based on a written order from the attending physician.8United Way of Connecticut. DNR – Do Not Resuscitate – Orders/Bracelet
Connecticut also uses a Medical Orders for Life-Sustaining Treatment (MOLST) form, printed on bright green paper so first responders can spot it quickly. The MOLST is broader than a DNR, covering resuscitation, ventilation, antibiotics, nutrition, and other treatment decisions. If a patient marks “DNR” on their MOLST, the MOLST can serve the same purpose as a DNR form or bracelet, and EMTs in outpatient settings will honor it. A patient can have both a MOLST and a DNR bracelet or transfer form at the same time.9State of Connecticut Department of Public Health. MOLST Overview and Frequently Asked Questions
Revoking a DNR Order
A patient or their authorized representative can revoke a DNR order at any time using either of two methods: physically removing the DNR bracelet, or verbally telling a licensed healthcare provider or certified EMT that the order is revoked.10Connecticut eRegulations. Regulations of Connecticut State Agencies 19a-580d-7 – Revocation No written form is required. A spoken statement is enough.
The provider or EMT who receives the revocation must enter its contents in the patient’s permanent medical record, and must notify both the attending physician and the physician who originally issued the DNR order. Once revoked, standard resuscitation protocols apply. If the patient later decides to reinstate the directive, a new DNR order and transfer form need to be executed from scratch.