Do Not Resuscitate (DNR) Order Information and Form

Do Not Resuscitate (DNR) Order

IMPORTANT NOTICE

This document provides information about DNR orders. Actual DNR forms vary significantly by state and must be signed by a physician (and often the patient or healthcare agent). Many states have specific statutory forms that must be used. Contact your healthcare provider or state health department for the appropriate form.

SECTION 1: UNDERSTANDING DNR ORDERS

1.1 What Is a DNR Order?

A Do Not Resuscitate (DNR) order is a medical order written by a physician that instructs healthcare providers NOT to perform cardiopulmonary resuscitation (CPR) if the patient's heart stops beating or if the patient stops breathing.

A DNR order only applies to CPR. It does NOT affect other medical treatments such as:

• Medications
• Surgery
• Dialysis
• Mechanical ventilation (unless separately addressed)
• Nutrition and hydration
• Pain management
• Other life-prolonging treatments

1.2 Types of DNR Orders

In-Hospital DNR:

• Written by a physician for a hospitalized patient
• Part of the patient's medical record
• Applies only within that healthcare facility

Out-of-Hospital DNR (also called Prehospital DNR or Non-Hospital DNR):

• A medical order that applies outside of healthcare facilities
• Recognized by emergency medical services (EMS)
• Must be in a format recognized by your state
• Usually a specific state-approved form, bracelet, or necklace

1.3 What CPR Includes

CPR and resuscitative measures that are withheld under a DNR order typically include:

• Chest compressions
• Mouth-to-mouth or bag-valve-mask ventilation
• Defibrillation (electric shock to the heart)
• Cardiac medications used during a code
• Intubation (insertion of a breathing tube)
• Advanced cardiac life support (ACLS)

1.4 Who Can Request a DNR Order?

• The patient (if capable of making healthcare decisions)
• The patient's healthcare agent (designated in a healthcare power of attorney)
• The patient's legal guardian
• In some states, a surrogate decision-maker (often a family member)

1.5 Who Must Sign a DNR Order?

In all states, a DNR order must be signed by:

• A licensed physician (MD or DO)
• In some states, a nurse practitioner or physician assistant

Many states also require the patient's signature (or the signature of the healthcare agent/surrogate).

SECTION 2: IN-HOSPITAL DNR ORDER FORM

Sample In-Hospital DNR Order

[// NOTE: This is a sample format. Hospitals have their own specific forms.]

[HOSPITAL NAME]

PHYSICIAN'S ORDER: DO NOT RESUSCITATE (DNR)

Patient Name: _______________________________________________

Date of Birth: _______________________________________________

Medical Record Number: _______________________________________________

Date: _______________________________________________

Time: _______________________________________________

PHYSICIAN'S ORDER:

☐ DNR - Do Not Resuscitate

In the event of cardiac or respiratory arrest, do NOT initiate cardiopulmonary resuscitation (CPR) or other resuscitative measures including but not limited to:

• Chest compressions
• Defibrillation
• Endotracheal intubation
• Artificial ventilation
• Cardiac resuscitation medications

Basis for Order:

☐ Patient's own decision (patient has decision-making capacity)

☐ Decision by healthcare agent pursuant to advance directive

☐ Decision by guardian/conservator

☐ Decision by surrogate (in accordance with state law)

☐ Other: _______________________________________________

Other Orders (if applicable):

☐ Continue all other treatments as medically indicated

☐ Comfort measures only

☐ Limited interventions (specify): _______________________________________________

Documentation:

☐ Patient's advance directive is in the medical record

☐ Healthcare power of attorney is in the medical record

☐ Discussion with patient/family documented in progress notes

PHYSICIAN SIGNATURE:

Signature: _______________________________________________

Printed Name: _______________________________________________

Date/Time: _______________________________________________

PATIENT/REPRESENTATIVE ACKNOWLEDGMENT:

☐ I have discussed this order with the physician and understand its meaning.

☐ I consent to this DNR order.

Signature: _______________________________________________

Printed Name: _______________________________________________

Relationship to Patient: _______________________________________________

Date: _______________________________________________

SECTION 3: OUT-OF-HOSPITAL DNR ORDER

3.1 State Requirements

Out-of-hospital DNR orders must comply with your state's specific requirements. Many states require:

• Use of a specific state-approved form
• Specific color (often yellow or pink)
• Specific format (wallet card, bracelet, necklace, full-page form)
• Physician signature
• Patient/representative signature
• Renewal or revalidation periodically

3.2 Sample Out-of-Hospital DNR Form

[// NOTE: This is a sample format. You MUST use your state's approved form.]

STATE OF [STATE]
OUT-OF-HOSPITAL DO NOT RESUSCITATE ORDER

[TYPICALLY PRINTED ON COLORED PAPER - CHECK STATE REQUIREMENTS]

PATIENT INFORMATION:

Name: _______________________________________________

Date of Birth: _______________________________________________

Address: _______________________________________________

Gender: ☐ Male ☐ Female

DNR ORDER:

I, the undersigned physician, certify that the above-named individual is my patient and has requested, or the patient's legally authorized representative has requested on the patient's behalf, that this Out-of-Hospital Do Not Resuscitate Order be issued.

I ORDER that in the event of cardiac or respiratory arrest, NO resuscitative measures shall be initiated or continued.

PHYSICIAN:

Signature: _______________________________________________

Printed Name: _______________________________________________

License Number: _______________________________________________

Phone: _______________________________________________

Date: _______________________________________________

PATIENT OR AUTHORIZED REPRESENTATIVE:

☐ I am the patient and I am making this decision for myself.

☐ I am the patient's authorized representative and I am making this decision on the patient's behalf because the patient lacks decision-making capacity.

I understand that this order means emergency medical services (EMS) personnel and other healthcare providers will NOT attempt cardiopulmonary resuscitation (CPR) if my/the patient's heart stops or breathing stops.

Signature: _______________________________________________

Printed Name: _______________________________________________

Relationship (if representative): _______________________________________________

Date: _______________________________________________

WITNESS (if required by state law):

Signature: _______________________________________________

Printed Name: _______________________________________________

Date: _______________________________________________

SECTION 4: INSTRUCTIONS FOR USE

4.1 For the Patient/Family

To obtain an out-of-hospital DNR order:

1. ☐ Discuss end-of-life wishes with your physician
2. ☐ Obtain your state's approved DNR form from:
   - Your physician
   - Hospital
   - State health department website
   - Hospice provider
3. ☐ Have the form completed and signed by your physician
4. ☐ Sign the form (or have authorized representative sign)
5. ☐ Keep the original in a visible, accessible location
6. ☐ Consider obtaining a DNR bracelet or necklace
7. ☐ Inform family members and caregivers
8. ☐ Provide copies to home health/hospice providers

4.2 Display and Accessibility

For EMS to honor an out-of-hospital DNR, it must be readily accessible:

☐ Posted on the refrigerator (common practice)
☐ Posted near the bed
☐ Kept in a visible location
☐ DNR bracelet or necklace worn by patient
☐ Wallet card carried by patient
☐ Copy provided to care facility

4.3 Revocation

A DNR order can be revoked at any time by:

☐ The patient (verbally or by destroying the form)
☐ The patient's healthcare agent
☐ The patient's guardian
☐ Writing "VOID" across the document
☐ Notifying the physician to cancel the order

SECTION 5: RELATED DOCUMENTS

5.1 DNR vs. Other Documents

5.2 Consider Also Completing

☐ Living Will/Advance Directive
☐ Healthcare Power of Attorney
☐ POLST/MOLST form (for seriously ill patients)
☐ Organ donor registration

SECTION 6: STATE-SPECIFIC RESOURCES

6.1 Find Your State's Form

State Health Department: _______________________________________________

State DNR Form Website: _______________________________________________

State DNR Hotline/Contact: _______________________________________________

6.2 Common State Variations

• Form Name: DNR, DNAR, AND, Allow Natural Death
• Form Color: Yellow, pink, orange (varies by state)
• Format: Full page, wallet card, bracelet, necklace
• Renewal: Some states require periodic renewal
• Witnesses: Some states require witness signatures
• Notarization: Rarely required, but check your state

SECTION 7: FREQUENTLY ASKED QUESTIONS

Q: Is a DNR order the same as "giving up"?
A: No. A DNR order is a personal choice about one specific intervention (CPR) based on values and goals. Patients with DNR orders can still receive full medical treatment, including hospitalization, surgery, medications, and comfort care.

Q: Can I still receive pain medication with a DNR?
A: Yes. A DNR only applies to CPR. Pain management and comfort care continue.

Q: What if my family disagrees with my DNR decision?
A: The patient's wishes take priority if the patient has capacity. Family education and discussion are important, but the patient's right to refuse CPR should be respected.

Q: Do I need a lawyer to get a DNR order?
A: No. A DNR is a medical order obtained from your physician. However, consulting with an elder law attorney about overall advance planning is recommended.

Q: Is a DNR order permanent?
A: No. You can revoke a DNR order at any time. Simply tell your healthcare providers you no longer want the DNR, and destroy or void the written order.

SECTION 8: DOCUMENTATION CHECKLIST

☐ DNR order signed by physician
☐ Patient/representative signature obtained
☐ Original kept in accessible location
☐ Copy in medical record
☐ Copy given to family members
☐ Copy given to care facility (if applicable)
☐ Copy given to hospice (if applicable)
☐ DNR bracelet/necklace obtained (optional)
☐ Family members informed and educated
☐ Decision documented in advance directive

This template provides general information about DNR orders. State laws regarding DNR orders vary significantly. You MUST use your state's approved form for out-of-hospital DNR orders. Consult with your healthcare provider and, if needed, an attorney to ensure proper documentation of your end-of-life wishes.