How to Set Up a DNR in Ontario for Home Palliative Care
If you're managing a loved one's palliative care at home in Ontario and want to ensure paramedics respect their do-not-resuscitate wishes, here's the direct answer: a Power of Attorney for Personal Care is not enough. You need a signed DNR Confirmation Form (Form 014-4519-45) — a specific clinical document that requires a physician or nurse practitioner's signature — positioned where paramedics are trained to look for it. Without it, Ontario paramedics are legally mandated to perform full resuscitation.
This is the single most misunderstood element of Ontario end-of-life planning. Families who have done everything right — POA-PC signed, treatment preferences documented, attorney appointed — still get blindsided when paramedics arrive and begin chest compressions because the clinical form wasn't in place.
Why a POA-PC Doesn't Stop Resuscitation
Under Ontario law, paramedics operate under base hospital medical directives, not family instructions. When they respond to a 911 call, they follow a standardized protocol: assess, stabilize, transport. The only document that legally authorizes them to withhold resuscitation is an original, signed DNR Confirmation Form.
Your POA-PC is a legal instrument under the Substitute Decisions Act, 1992. It names an attorney and may contain treatment preferences. It sits in a filing cabinet. Paramedics do not read it — not because they're ignoring your wishes, but because their legal authority comes from the Ministry of Health's medical directives, not from the Substitute Decisions Act. Two different legal systems, two different chains of authority.
Step 1: Get the DNR Confirmation Form Signed
The DNR-C form (Form 014-4519-45) must be signed by a physician or nurse practitioner who has examined the patient and confirmed the medical appropriateness of a DNR order. The form is not patient-initiated — a family cannot fill it out themselves.
How to request it:
- Speak with the patient's primary care physician or the palliative care team lead. Explain that the patient (or their SDM/attorney) wants a DNR order documented in the format paramedics recognize.
- If the patient has capacity, they confirm the wish directly. If the patient lacks capacity, the attorney under the POA-PC or the highest-ranked SDM under the HCCA hierarchy provides substitute consent.
- The physician or nurse practitioner completes and signs the form. Family members cannot sign it; the clinician must have obtained informed consent from the patient (if capable) or their SDM.
- The physician retains a copy in the clinical file. The original goes home with the patient.
Common obstacle: Some physicians are unfamiliar with the form or believe a verbal order or chart note is sufficient. It isn't — paramedics require the specific form number. If the physician doesn't have copies, the form is available from Ontario's Central Forms Repository (Form 014-4519-45) or through Ontario Health atHome / the regional palliative care team.
Step 2: Position the Form Where Paramedics Will Find It
Ontario's emergency medical services train paramedics to look for the DNR-C form in specific locations:
- On or near the refrigerator — this is the standard placement taught in paramedic training across Ontario. A bright-coloured envelope or folder (not white — it blends into the wall) taped at eye level.
- Near the front entrance — if the home's layout means paramedics enter through a different door than the kitchen, a second visible copy near the main entry point.
- On the patient's person — some families keep a copy with the patient, particularly if they move between rooms or floors of the home.
The form must be the original signed document, not a photocopy. Keep the original accessible — locked in a safe defeats the entire purpose.
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Step 3: Set Up the EDITH Protocol
The Expected Death in the Home (EDITH) protocol is the coordination framework that prevents the DNR-C from being overridden by a well-meaning but incorrect 911 call.
Here's the problem EDITH solves: even with a valid DNR-C posted on the refrigerator, if a family member panics and calls 911 when the patient dies, the dispatch system triggers a full emergency response. Paramedics will look for the DNR-C and withhold CPR if they find the original, but a 911 call still brings sirens, scene control, and the risk that the form cannot be located in time — which legally mandates resuscitation. EDITH exists so that call never happens.
EDITH coordination steps:
Register with the palliative care team. The patient's home-care nursing team, hospice coordinator, or palliative care physician should document the patient as an EDITH-registered case. This means the care team has an established protocol for what happens when death occurs.
Designate a "first call." When death occurs at home, the family's first call should be to the palliative care nurse or the on-call physician — not 911. The nurse or physician confirms death, and the process moves to pronouncement and funeral arrangements without triggering emergency services.
Brief all family members and caregivers. Every person who might be present at the time of death needs to know: call the palliative nurse first, not 911. This includes overnight caregivers, visiting family members, and anyone staying in the home. A posted instruction card near each phone (and saved in mobile contacts) reduces the chance that grief and shock override the plan.
Confirm funeral home arrangements in advance. Once death is pronounced by a home-care RN or RPN under the EDITH protocol, the physician or NP submits the Medical Certificate of Death within 24 hours and the funeral home handles transport. Having the funeral home's contact information posted alongside the EDITH instructions prevents the scramble that leads to a default 911 call.
Step 4: Coordinate with Long-Term Care (If Applicable)
If the patient splits time between home and a long-term care facility, the DNR-C form needs to travel with them. Long-term care homes in Ontario have their own consent and DNR documentation processes, but the DNR-C form is the document paramedics recognize during transport or if emergency services are called at the facility.
Make sure the facility's medical director has a copy on file and that the original DNR-C moves with the patient between settings. Each transition — home to hospital, hospital to LTC, LTC to home — is a point where the form can be lost or separated from the patient.
What Most Planning Resources Miss
Most Ontario advance directive guides — whether free government forms, online platforms, or lawyer-prepared packages — stop at the legal layer. They help you sign a POA-PC and maybe a CPOA. The clinical layer (DNR-C and EDITH) and the coordination layer (placement, family briefing, care transitions) are left to the family to figure out on their own, usually under crisis conditions.
The Ontario Advance Directive & Living Will Kit covers all three layers in sequence: legal documents first, then clinical protocols including the DNR-C walkthrough and EDITH coordination framework, then financial protections. For families managing home palliative care, the clinical layer is where the real-world gap sits.
Who This Is For
- Families managing a terminal illness or advanced decline at home in Ontario
- Anyone whose loved one has expressed do-not-resuscitate wishes and needs them documented in a format paramedics will follow
- Home-care teams coordinating end-of-life plans across multiple caregivers and family members
- Families in rural or northern Ontario where the distance between home and hospital makes the EDITH protocol particularly important
Who This Is NOT For
- Families whose loved one wants full resuscitation — a DNR-C is only appropriate when the patient or their legal SDM has decided against CPR and advanced life support
- Patients in hospital — in-hospital DNR orders follow a different documentation process through the attending physician's orders
- Anyone looking for legal advice on capacity disputes — if the patient's wishes are contested, a lawyer or the Consent and Capacity Board is the appropriate resource
Frequently Asked Questions
Can I set up a DNR without a Power of Attorney for Personal Care?
The DNR-C form itself doesn't require a POA-PC — it requires a physician's signature and the patient's (or SDM's) consent. However, without a POA-PC, the question of who has authority to consent to the DNR order falls to the HCCA's SDM hierarchy, which can create delays or disputes among equally ranked family members. Having a POA-PC in place before pursuing a DNR-C simplifies the consent chain.
What if a family member calls 911 anyway?
Paramedics responding to a 911 call will look for the DNR-C form. If they find a valid, signed original, they are authorized to withhold resuscitation. If they can't locate it, they must begin full resuscitation. This is why placement and family briefing are essential — the form is useless if it's in a filing cabinet during the critical minutes after a 911 dispatch.
Does a DNR-C form expire?
Ontario's DNR-C form does not have a built-in expiration date, but it should be reviewed and re-signed if the patient's medical condition changes significantly, if they change care settings, or if the attending physician changes. Some palliative care teams recommend annual reviews as part of the advance care planning process.
Can I download the DNR-C form online?
Form 014-4519-45 is available from Ontario's Central Forms Repository and through Ontario Health atHome and regional palliative care teams. The form itself is not patient-completed — it must be filled out and signed by a physician or nurse practitioner. The kit's DNR-C chapter walks through the process of obtaining the clinical signature and coordinating placement.
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