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Get a POLST form for your state (look on your state's own website, you'll find all this kind of paperwork there) and adapt it. It should work fine.

Just curious: decline going to hospital... for fear of catching something nasty? For altruistic reasons, so as not to absorb resources? I hope the person has thought this through carefully, anyway.

I hope even more devoutly that the form won't be wanted at all. God willing.
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The OP is saying can the resident decline. If competent, they can decline. If they have the virus, they will need to be quarantined. Nursing home or not, residents have rights by law. You cannot force a resident (not patient, they r called residents because the NH is now their home) to dobwhat they don't want to.
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Where I live I've heard there is a push on to contact every family to make sure advanced directives are in place and to let them know that anyone in a nursing home who contracts covid19 will not be hospitalized - it sounds like a huge exercise in c.y.a. since basically the only advanced directive accepted will be a level 1 or 2 DNR.
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Their going to just have to go along with whatever path the facility is taking for residents care plans during this emergency. The resident or their dPOA at a NH is not going to the option to decide on their own whether to stay at NH or go to ER or to a hospital or move to a Covid care popup. Once your in a NH/SNF your care is under the MD who is the medical director of the facility. The medical directors are going to be under whatever emergency pandemic rules are for your region.

US is way way way past the point of trying to micro-decision what to do taking each individuals concern or situation in mind for Covid. To do that, mass testing & contact tracking nationwide & fever clinics would have rolled out 8 -9 weeks ago. US is moving into triage care decision making for most of the country by next week.
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There was a mention by the presidents task force on Thursday that NH would be separating the sick folks from the well which made it sound like there was already a plan NOT to take them to the hospital in play unless what? I don’t know. They needed services like the nonexistent ventilators? Perhaps. I’m sure these rules would be different depending on whether the patient is in NY or one of the states where the number of cases hasn’t overwhelmed the system.
I think each location is taking the steps their local governments have dictated that is if it’s even being addressed. I would contact your NH as JoAnn mentioned and understand their intentions on how to handle sick residents and be aware that the situation is fluid and could change. Watch your local news and your local government websites.
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igloo572 Apr 2020
“They needed services like the nonexistent ventilators”
this needs to be an epitaph on every Covid-19 death obituary
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If they are competent they can decline. If not and have a POA, I would think the POA would be called before transporting. All u can do is cal, the NH and ask them.
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