DNR and POLST Orders on NEMT Rides: What Drivers Do When a Rider Stops Breathing

Sooner or later a rider will hand your driver a form, or a facility nurse will say “she’s a DNR” at pickup. Your driver needs to know what that changes. The short answer is very little about the first five minutes, and a lot about what the driver hands the paramedics.

This guide covers what these orders are, who they bind, and the protocol for the moment a rider with an order stops breathing. For every other emergency on the road, follow the steps in medical emergency during a NEMT ride.

What DNR and POLST orders are

A do-not-resuscitate (DNR) order is a medical order not to attempt CPR if a person’s heart or breathing stops. Texas’s out-of-hospital version lists what it withholds: CPR, advanced airway management, artificial ventilation, defibrillation, and transcutaneous cardiac pacing. It does not allow withholding comfort care, pain relief, water, or nutrition (Texas Health and Safety Code 166.081).

A POLST form is a broader portable medical order. National POLST describes it as part of advance care planning for people who are seriously ill or have advanced frailty, and having one is optional. The form records whether the person wants CPR attempted, whether they want to go to the hospital or stay where they are, and whether they want intensive care and a breathing machine. The provider signs it, and most states also want the patient’s or a surrogate’s signature.

Each state runs its own program and picks its own name. On the National POLST state directory:

• POLST in California, Florida, and Texas.
• MOLST in New York and Maryland.
• MOST in Colorado and North Carolina.
• POST in Virginia and West Virginia, and LaPOST in Louisiana.

One point matters most on a ride. A DNR order, like the CPR choice on a POLST form, applies only when the heart or breathing has stopped. Florida’s DNRO covers respiratory or cardiac arrest, and Pennsylvania’s order works the same way. A rider with a DNR who is choking, bleeding, having a seizure, or reporting chest pain still gets 911 and the first aid your driver is trained to give. The rest of a POLST form, such as whether to go to the hospital, is for the crew to read.

Who a DNR order binds, state by state

In the six states below, the law addresses EMS crews, other emergency responders, and licensed clinicians. None of them makes a NEMT driver the person who decides whether an order applies, though Pennsylvania’s rule can reach a driver who uses an AED (see below).

State	The form EMS looks for	Who the law addresses
Texas	The OOH-DNR form, or a DNR ID bracelet or necklace	Physicians, physician assistants, nurses, and EMS
Florida	The DNRO, form DH 1896, on yellow paper	Florida EMTs and paramedics only
New York	The one-page nonhospital DNR form (DOH-3474) or a MOLST form (DOH-5003)	EMS, hospice, home care agency, and hospital emergency staff
California	A POLST form or the state prehospital DNR form	Licensed providers, plus firefighters, police, EMTs, and paramedics trained to state EMS standards
Pennsylvania	An out-of-hospital DNR order, bracelet, or necklace	EMS providers, including a bystander using an AED under Good Samaritan protection
Virginia	A Durable DNR, POST, or POLST form, or approved DNR jewelry	EMS, and licensed practitioners in state-licensed facilities and programs

The sources are Texas Health and Safety Code 166.081 and 166.089, Florida Statutes 401.45 (2026) and the Florida Department of Health’s DNRO page, New York Public Health Law 2994-aa, 2994-dd, and 2994-ee with the health department’s MOLST letter of May 1, 2025, California Probate Code 4780, 4781, and 4781.2, the Pennsylvania Department of Health’s out-of-hospital DNR questions and answers, and Virginia Code 54.1-2987.1 with 12VAC5-66 (amended effective February 12, 2026).

Pennsylvania has one detail worth teaching. Its health department counts a person with Good Samaritan protection who uses an automated external defibrillator as an EMS provider under the Out-of-Hospital Nonresuscitation Act, and the Act requires EMS providers to follow an order displayed with the person. A Pennsylvania driver who uses an AED on a rider may fall inside that rule, so ask your attorney how it applies to your staff.

Federal rules point the same way. Under 42 CFR 489.102, hospitals, nursing facilities, home health agencies, hospices, and a few other providers must keep written policies on advance directives. Transportation companies are not on that list. The facility or hospice that sends the rider holds the paperwork and the policy, so ask them.

Why a facility’s DNR may not count in the van

A resident can be “DNR” in a nursing home’s chart and still have nothing EMS can follow once the van leaves the lot. States treat the facility’s own order differently:

• Texas. EMS can honor only a properly completed OOH-DNR form or a DNR ID device. The state’s guide for health care professionals says crews will not consider other written documents, even from a doctor. They contact their medical director and start care.
• Pennsylvania. EMS providers may not recognize DNR orders that do not meet the Act’s appearance rules. The health department tells people who leave a nursing home or hospital, and do not want CPR, to get an out-of-hospital order from their attending physician.
• Virginia. Crews honor a facility’s own DNR order as if it were a Durable DNR when the patient is admitted to, or in transit from, a qualified health care facility, and the order has the required information (12VAC5-66-60).
• Florida. The DNRO is a limited direction to paramedics and EMTs, and they need not interpret any other DNR, advance directive, or POLST document. A patient may still hold both a DNRO and other written directions about resuscitation.

So when a facility tells you a rider is a DNR, ask one question: which form is going with the rider today?

Copies, phone photos, and bracelets

• Texas. A photocopy may be used like the original (Health and Safety Code 166.083). The state FAQ says a photo on a cell phone is not a copy. The order or a copy must go with the person during medical transport.
• Florida. Copies are valid only with a full yellow background or on yellow paper of any shade. The form comes with a wallet-size “DNRO device” the person can carry.
• Virginia. An original or a legible photocopy must be readily available at the patient’s current location (12VAC5-66-40).
• New York. Under state law, MOLST is the only form that records both a nonhospital DNR and a do-not-intubate order. A MOLST printed on any color paper is valid, though the health department strongly encourages pink, and the signed form should travel with the patient between care settings (MOLST page revised June 2025; letter of May 1, 2025). OPWDD’s CPR alert (update August 2022) tells agency staff to look for it on bright pink paper in the person’s record.
• Pennsylvania. The health department describes crews looking for the order with original signatures, displayed with the person. An order found in a drawer, or a bracelet not on the person, can lead EMS to treat the order as revoked.
• Everywhere else. National POLST says faxed and photocopied POLST forms are valid in almost all states, and suggests a copy in the person’s purse or wallet near their ID when traveling.

What the driver does when a rider with an order stops breathing

The protocol has one goal: get the crew to the rider fast, with the form in hand. Print it on the van card next to your other emergency steps.

1. Stop safely. Pull out of traffic, park, and turn on the hazard lights.
2. Check the rider. Say their name, tap a shoulder, and watch for normal breathing.
3. Call 911, even with an order. Florida’s health department says to call 911 even when the patient has a DNRO, because crews give comfort care and can still take the person to a hospital. Tell the call-taker that the rider has a DNR or POLST form.
4. Follow your written CPR rule and the call-taker’s instructions. The next section explains how to set that rule.
5. Find the form or device. Look where the facility or family said it would be, such as a pocket on the wheelchair or the rider’s bag. Hold it ready for the crew.
6. Call dispatch. Say where you are, that 911 is coming, and who else is aboard.
7. Hand the form to the crew and step back. Say who gave it to you and when. The crew checks it, not you. In Texas the responding professionals confirm the person’s identity, the signatures, and the date (Health and Safety Code 166.089), and Pennsylvania crews who are unsure start CPR until their medical command physician decides.
8. Pass on what you hear at the scene. If the rider, a guardian, or a relative says the rider wants CPR, tell the crew at once. In Texas, the rider, or the guardian, relative, or health care agent who signed the order, can revoke it by telling the crew at the scene (166.092).
9. Stay until the crew takes over, and follow their directions.
10. Write the times down: when you stopped, called 911, called dispatch, and when the crew arrived.

Should your driver start CPR?

This is the question the laws above leave open for drivers, so your company has to answer it. CareOregon’s provider manual (February 2024), for one, requires every provider to set written procedures for drivers when a member needs emergency care.

You have two workable rules:

• Start CPR on any rider who is not breathing, and let the crew stop it. The driver never reads a form. This matches what Pennsylvania tells its own EMS crews to do when they are unsure about an order.
• Hold CPR when the rider’s state order is in hand, and give it to the crew. New York’s Office for People With Developmental Disabilities tells agency staff to start CPR unless the person has a DNR order, not to perform CPR if there is one, and to know where the order is so EMS can see it (Health and Safety Alert, update August 2022). This honors the rider’s wishes sooner, but it asks the driver to recognize the right form under stress.

Pick one before it happens. Have a health care attorney review it, tell your brokers, facilities, and hospices which rule you use, and train every driver on it before the first ride. A driver who has never heard the rule will guess.

Before the ride: keep the order with the rider

Most DNR problems on a ride start at booking.

1. Ask at intake. For hospice, nursing home, and dialysis riders, ask the facility or family whether the rider has a DNR or POLST form, and which state form it is. See NEMT trip intake.
2. Record only what the driver needs. “Has a DNR form, travels in the bag on the wheelchair” is enough. If your company is covered by HIPAA, the minimum necessary rule asks you to limit what you use and share to what the job needs (45 CFR 164.502(b)). See HIPAA for NEMT.
3. Check at pickup. The driver confirms the form is with the rider, not in the facility’s office. In Pennsylvania an order left behind may not count.
4. Never keep it in the van. The form belongs to the rider. Texas’s form says it, or a copy, must go with the person during medical transport, and Virginia’s rules keep the order with the patient during transport (12VAC5-66-80).
5. Hand it back at drop-off. It goes into the building with the rider.

Cross-state trips need one more check. Texas accepts valid DNR forms from other states, and Virginia law treats another state’s order as valid. Pennsylvania’s crews may follow another state’s out-of-hospital order only if the health department has approved that state’s rules, and its questions and answers (April 2016) say it has approved none. Florida’s DNRO is directed only to Florida EMS, and the state tells people to check the law where they will be. See out-of-state NEMT trips.

Hospice riders and facility contracts

Many riders with orders come from hospices and nursing homes. Settle the DNR steps with them in writing, not on the curb.

• Hospices. Add a line to the agreement on what the crew does when a patient’s condition changes: whether the driver calls 911, the hospice’s 24-hour line, or both, and in what order. The hospice transportation guide has the full agreement checklist.
• Nursing homes and assisted living. Ask the facility to send its state’s out-of-hospital form, not only its internal order, with any resident who has one.
• Dialysis centers. Ask the clinic to tell you when a standing-order rider’s status changes, so the driver is never the last to know.

After a death or an EMS call: reports and your driver

When EMS responds to a rider in your van, the trip becomes an incident, whatever the outcome. Phone the broker at once, then send the written report on its clock. New York wants a death or ambulance response reported to the transportation manager immediately (state policy, February 2022), and Louisiana wants a written report within 72 hours when a rider dies in your care (manual issued July 14, 2025). The medical emergency guide lists the clocks for more brokers and states.

On the incident report, add three facts for these trips: that the rider had an order, who handed the form to the driver and when, and that it went to the EMS crew. Write what was seen and done, with times.

Then look after the driver. OPWDD’s CPR alert tells agencies to debrief after any incident where life-saving steps were taken, and to address the emotional support needs of the staff involved. Do the same. Offer a break or a relief driver before the next run, walk through the steps together within a few days, and fold anything you learn into your driver training. If your drivers are certified, the CPR requirements guide covers renewals and which courses count.