Medical Director Message July 2026

Dr. Jeffrey Luk

Dr Luk is the EMS Medical Director for departments under UH Cleveland Medical Center

July 6, 2026

Ohio DNR Rules & Regulations for Paramedics

Ohio's Do-Not-Resuscitate (DNR) protocol, governed by Ohio Administrative Code (OAC) Chapter 3701-62 and Ohio Revised Code (ORC) §§ 2133.21–2133.26, establishes the legal framework that all EMS personnel, including paramedics, must follow when encountering patients with DNR orders.1 Most recently updated effective September 8, 2025, these rules clarify provider authority, documentation standards, and EMS obligations in the field.2

Two Types of DNR Orders

Ohio recognizes exactly two DNR classifications.1 The first, DNR Comfort Care (DNRCC), activates the moment a DNR order is issued, meaning no resuscitative measures are to be performed from that point forward. The second, DNR Comfort Care – Arrest (DNRCC-Arrest), activates only upon cardiac or respiratory arrest — full medical treatment continues until that moment.1 Understanding this distinction is critical for paramedics, as it directly determines what care may be provided on scene.

What Counts as CPR — and What Doesn't

CPR includes chest compressions, artificial airway insertion, resuscitation drugs, defibrillation, respiratory assistance, resuscitative IV lines, and cardiac monitoring.1 Importantly, clearing a patient's airway for a non-CPR purpose is not considered CPR and remains permissible.1 Even with a valid DNR in place, paramedics are still required to provide comfort care — including pain management, hydration for comfort, suctioning, and repositioning — as a DNR is NOT a "do not treat" order.1

Valid DNR Identification

EMS personnel must recognize legally valid DNR identification, which includes the official Ohio DNR order form, wallet cards, hospital-type bracelets, necklaces, and operative Living Will declarations containing CPR refusal language.1 All identifiers must bear the official DNR Comfort Care logo and the patient's name. Jewelry for DNRCC-Arrest patients must also include the word "ARREST."1 Critically, the DNR order form cannot be written upon or altered — any additions are not legally transportable.1

EMS Obligations and Protections

Paramedics must comply with the DNR protocol when presented with valid DNR identification, a written DNR order, or a direct oral DNR order from an authorized provider.3 When an off-scene provider issues an oral DNR order, EMS must verify the provider's identity before complying.3 In emergencies, EMS is not required to search a patient for DNR identification.3 Paramedics acting in good faith under a valid DNR are fully protected from criminal prosecution, civil liability, and professional disciplinary action.1

Revocation and Patient Rights

A DNR can be revoked at any time — including mid-emergency — by the patient making an oral or written request for CPR, destroying their DNR documentation, or permanently removing DNR jewelry.1 If a patient verbally requests CPR, paramedics must honor that request immediately, regardless of any DNR documentation present.1

Family members cannot revoke a DNR on behalf of a competent patient; however, this situation has the risk of becoming volatile, so contact medical control if you need to.

2025 Updates & Key Takeaways

The 2025 rule updates expanded authority for APRNs and PAs to issue DNR orders without a physician co-signature; clarified the hierarchy between DNR orders, Living Wills, and Healthcare Powers of Attorney; and reinforced transport documentation requirements.2 When in doubt on scene, paramedics should contact medical control immediately and document all actions thoroughly.3

Thank you for your time,

Jeffrey Luk, MD, MS

Sources:

July 13, 2026

Patient refusals represent one of the highest medicolegal risk situations in all of EMS — and for Ohio paramedics, the stakes are particularly significant. What may feel like a routine, low-acuity call can quickly become the foundation of a civil lawsuit, an Ohio EMS Board investigation, or even criminal exposure if not handled with precision, documentation, and clinical rigor.1

The Ohio Legal Landscape

Ohio law under ORC § 4765.49 provides paramedics with immunity from civil liability for damages arising from the administration of emergency medical services.2 However, this protection is conditional; it evaporates entirely when services are rendered in a manner that constitutes willful or wanton misconduct.2 This means that a poorly executed refusal — one involving an incomplete assessment, falsified documentation, or a failure to assess patient capacity — can strip a paramedic of immunity and expose them to the full force of civil litigation. Beyond civil liability, Ohio paramedics also face administrative action through the Ohio EMS Board under ORC § 4765.101 and § 4765.111, which can result in suspension or permanent revocation of a paramedic certificate.1,3 In the most serious cases, criminal prosecution remains a real, if rare, possibility, particularly when documentation is falsified.1

Capacity Is Not an Assumption

A legally valid refusal requires that the patient possess decision-making capacity at the time of the refusal. Capacity is a medical determination made by the paramedic on scene, and it requires that the patient be able to understand that a decision must be made, comprehend the specific risks of refusing care, communicate those risks back to the provider, and act free of coercion.1 Common capacity killers — including hypoxia, shock, intoxication, dementia, and pediatric age — must be actively assessed and documented. Ohio law under ORC § 4765.162 mandates dementia-specific training for all EMS providers, recognizing how easily this population can appear oriented while lacking true decision-making capacity.1, 3

The Hidden Danger: Provider-Induced Refusals

One of the most underappreciated risks is the provider-induced refusal: when a paramedic, intentionally or not, steers a patient away from transport by minimizing symptoms, emphasizing cost or inconvenience, or signaling that staying home is reasonable. This conduct can be reframed legally as patient abandonment and can transform a defensible refusal into a gross negligence claim.1

Documentation Is Your Defense

Every refusal must be supported by a complete, accurate, and specific Patient Care Report (PCR). This means documenting a full set of vital signs, a thorough mental status and capacity assessment, the specific risks explained to the patient in plain language, the patient's own words repeating those risks back, any family or bystander involvement, and encouragement to call back at any time.1 Investigators now routinely examine ePCR metadata, timestamps, and even surveillance footage, making documentation integrity more critical than ever.1

Best Practices: The FEARS Framework

Ohio paramedics should apply the FEARS framework on every high-risk refusal: conduct a Full exam with vitals; Explain Real risks in condition-specific terms; Ask for assistance from family or Medical Control; Record the discussion thoroughly; and maintain a Supportive attitude throughout.1

Contacting Medical Control on high-risk refusals is especially important; it increases the likelihood of patient compliance, documents appropriate escalation, and protects the paramedic from claims of unilateral decision-making.1

The Bottom Line

There is no such thing as a routine refusal. Every patient who declines care deserves the same clinical rigor and documentation discipline as any critical transport. Ohio's immunity statute protects paramedics who act within their protocols, but it will not shield those who cut corners, skip assessments, or falsify records.2, 3 The paramedic's best legal protection is always a thorough assessment, an honest conversation with the patient, and a complete, accurate PCR.

This summary is for educational purposes only and does not constitute legal advice.

Thank you for your time,

Jeffrey Luk, MD, MS

Sources:

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