Medical Directive - Out-of-Hospital DNR

TEXAS OUT-OF-HOSPITAL DNR REQUEST AND CLINICAL WORKSHEET

Not an OOH-DNR Order or Identification Device

CRITICAL NOTICE: Signing this worksheet does not create a Texas OOH-DNR order and does not direct health care professionals to withhold resuscitation. Use the current two-sided Texas Department of State Health Services form, effective 10/2023, and complete the correct declaration route, attending-physician statement, witness or notary process, and final acknowledgment signatures. Texas HHS updated its completion instructions in May 2026.

Use this worksheet to identify the proper execution route and prepare for completion of the official form.

1. PERSON INFORMATION

2. REQUEST FOR DISCUSSION

I request a discussion about Texas's out-of-hospital DNR process and the effect of refusing the five resuscitation measures listed on the official form.

My present preference for discussion is:

☐ In respiratory or cardiac arrest, I do not want the listed resuscitation measures initiated or continued.

☐ In respiratory or cardiac arrest, I want resuscitation attempted and do not request an OOH-DNR.

☐ I am undecided and want the choices, consequences, and other advance directives explained.

Values, goals, concerns, or questions:

[____________________________________________________________]

[____________________________________________________________]

Optional person / representative signature (documents this request only):

Signature: [________________________________] Date: [__/__/____]

Printed name and asserted authority, if not the person:

[____________________________________________________________]

This signature is not an OOH-DNR order and does not establish representative authority.

3. SELECT EXACTLY ONE OFFICIAL DECLARATION ROUTE

Route A — competent adult

☐ Person is competent and at least eighteen and will sign Section A.

Route B — guardian, medical-power-of-attorney agent, or directive proxy

☐ Adult is incompetent or otherwise unable to communicate.

☐ Declarant is the legal guardian, medical-power-of-attorney agent, or proxy in a directive to physicians and will sign Section B.

Route C — qualified adult relative

☐ Adult is incompetent or otherwise unable to communicate and has no legal guardian, agent, or proxy.

☐ Available declarant qualifies under the statutory priority: spouse, reasonably available adult children, parents, or nearest living relative.

☐ Qualified relative will sign Section C based on known desires or best interest.

Route D — attending physician based on prior directive or nonwritten issuance

☐ Attending physician saw evidence of a previously issued directive to physicians by the now-incompetent adult; or

☐ Attending physician observed a competent adult issue an OOH-DNR in a nonwritten manner before two witnesses.

☐ Attending physician will complete Section D and the physician's statement.

Route E — minor with terminal or irreversible condition

☐ Person is under eighteen.

☐ Physician diagnosed a terminal or irreversible condition.

☐ Parent, legal guardian, or managing conservator will sign Section E.

Route F — two-physician pathway

☐ Adult is incompetent or unable to communicate.

☐ No guardian, agent, proxy, or available qualified relative can act.

☐ Attending physician determined the person's specific wishes are unknown and resuscitation is ineffective or not in the person's best interest.

☐ Second physician is not involved in treatment or is a representative of the facility's ethics or medical committee.

☐ Both physicians will complete Section F.

Selected route: [A / B / C / D / E / F]

Authority / route notes:

[____________________________________________________________]

4. CLINICAL DISCUSSION

Attending physician: [________________________________]

Texas license number: [________________________________]

Discussion date: [__/__/____]

The current OOH-DNR form withholds or withdraws these measures in respiratory or cardiac arrest:

☐ Cardiopulmonary resuscitation

☐ Transcutaneous cardiac pacing

☐ Defibrillation

☐ Advanced airway management

☐ Artificial ventilation

☐ The person or declarant understands that the order does not prevent other emergency care, including comfort care.

☐ Other Texas advance directives and treatment choices were discussed as appropriate.

☐ Known desires or best-interest basis was documented for a representative decision.

Clinical notes:

[____________________________________________________________]

[____________________________________________________________]

5. COMPLETE THE SELECTED DECLARATION SECTION

Use only the official form and complete the selected route:

☐ Full legal name, date of birth, and current identifying fields entered.

☐ Correct route box or boxes selected.

☐ Declarant signed and dated the applicable Section A, B, C, D, or E; or both physicians completed Section F.

☐ Printed names and physician license numbers entered where required.

☐ Representative authority was verified and retained in the medical record.

☐ For Route D, the attending physician completed both the declaration route and physician's statement.

☐ For Route F, both physicians meet the route requirements and completed their entries.

Do not select multiple competing routes or attach this worksheet as a declaration.

6. WITNESS OR NOTARY PROCESS

For Routes A through E, use one of the permitted authentication paths:

Option 1 — two witnesses

☐ Witness 1 is a competent adult and satisfies every disinterested-witness restriction on the form.

☐ Witness 2 is a competent adult.

☐ Both witnessed the applicable person's or declarant's signature.

☐ For a Route D nonwritten issuance, both witnesses observed the competent adult's nonwritten communication to the attending physician.

Option 2 — notary

☐ Competent adult or authorized declarant signed before a Texas notary.

☐ Notary completed the official acknowledgment and seal.

A notary cannot acknowledge a Route D nonwritten issuance; that route requires two qualified witnesses. Route F requires neither witness nor notary signatures.

Authentication path selected: ☐ Two witnesses ☐ Notary ☐ Route F exception

7. ATTENDING-PHYSICIAN STATEMENT AND FINAL SIGNATURES

Except as addressed through the complete two-physician pathway, the current form requires the attending physician's statement.

☐ Attending physician signed and dated the physician's statement.

☐ Attending physician printed name and license number.

☐ Existence of the order noted in the person's permanent medical record.

☐ Every person who signed above signed again in the bottom acknowledgment section.

☐ Electronic or digital signatures, if used, satisfy Tex. Health & Safety Code § 166.011 and the form's requirements.

☐ Entire form reviewed for missing dates, unchecked route boxes, incomplete license information, or missing repeat signatures.

The official FAQ warns that responding professionals may refuse to honor an incorrectly completed form, including a form missing required final acknowledgment signatures.

8. ORDER EFFECT AND OUT-OF-HOSPITAL SETTINGS

The official form becomes effective immediately on execution for health care professionals acting in out-of-hospital settings and remains effective until the person is pronounced dead or the order is revoked.

The form applies in out-of-hospital settings identified by Texas law and guidance, including:

☐ Private residence or public location

☐ Long-term care facility

☐ Inpatient hospice facility

☐ Physician's office

☐ Hospital clinic, outpatient department, or emergency department

☐ Vehicle during transport

Admission to an acute-care hospital does not itself “automatically revoke” the order. The out-of-hospital statute and form govern the listed settings; inpatient DNR orders are addressed through the applicable hospital process.

9. PAPER FORM, COPY, AND APPROVED DEVICE

Responding professionals may honor:

☐ Original fully and properly completed OOH-DNR form

☐ Paper copy of the fully and properly completed form

☐ Approved OOH-DNR identification device worn by the person

The official FAQ states that a cellphone image or photo is not a substitute paper copy.

Device review:

☐ Official form was fully completed before ordering a device.

☐ Device obtained from a currently approved manufacturer at the person's expense.

☐ Plastic device is intact, unaltered, easily identifiable, and bears the required Texas / DNR markings.

☐ Metal bracelet or necklace is intact, unaltered, easily identifiable, and bears “Texas Do Not Resuscitate – OOH.”

☐ Caregivers know that the approved device may be honored in lieu of the paper form.

Access / device notes:

[____________________________________________________________]

10. TRANSPORT AND RECORDS

☐ Operative order entered in the permanent medical record.

☐ Original retained in a known, accessible location.

☐ Paper copies provided to appropriate caregivers and facilities.

☐ Form or approved device will accompany the person during medical transport.

☐ Receiving professionals will be told about the order before or at handoff.

☐ This worksheet will not be presented as an OOH-DNR order.

Transfer / access notes:

[____________________________________________________________]

11. REVOCATION AND CIRCUMSTANCES REQUIRING RESUSCITATION

The official instructions state that the person, authorized representative, or physician who executed the order may revoke it at any time by:

☐ Verbal communication to responding health care professionals

☐ Destruction of the OOH-DNR order

☐ Removal of all OOH-DNR identification devices from the person

The official form also identifies automatic revocation when the person is known to be pregnant or in unnatural or suspicious circumstances.

Do not rely on this worksheet alone to revoke the order. Immediately notify health care professionals, caregivers, facilities, and the attending physician and address all paper copies and devices.

Revocation / change notes:

[____________________________________________________________]

[____________________________________________________________]

12. CURRENT OFFICIAL SOURCES

• Texas Health and Safety Code, Chapter 166, Advance Directives — https://statutes.capitol.texas.gov/Docs/HS/htm/HS.166.htm
• Texas HHS Forms and Handbooks, OOH-DNR form page, effective 10/2023; instructions updated 05/2026 — https://fhb.hhs.texas.gov/forms/advance-directives/out-hospital-do-not-resuscitate-ooh-dnr-order
• Texas DSHS, current OOH-DNR Order and instructions — https://www.dshs.texas.gov/sites/default/files/emstraumasystems/DNR/pdf/DNR_Form.pdf
• Texas DSHS, Completing the Texas OOH-DNR Form — https://www.dshs.texas.gov/sites/default/files/emstraumasystems/DNR/pdf/Completing-OOH-DNR-Form.pdf
• Texas DSHS, OOH-DNR Frequently Asked Questions — https://www.dshs.texas.gov/sites/default/files/emstraumasystems/DNR/pdf/faqsfordnr.pdf

This worksheet is for preparation and clinical intake only. Verify the current Texas statutes, administrative rule, HHS / DSHS form, approved-device list, and EMS or facility procedures before completing or relying on an OOH-DNR order.