Free Do Not Resuscitate (DNR) Form

Table of Contents

1. Do Not Resuscitate Form (PDF & MS Word)
2. What is a DNR Form?
3. When is a DNR Appropriate?
4. How to Get a DNR Form
5. Do Not Resuscitate Laws by State

1. Do Not Resuscitate Form (PDF & MS Word)

Printable Do Not Resuscitate Form (MS Word)

The Do Not Resuscitate form PDF below is a sample. It details an order from the patient, ‘Michelle R Kane’, and an affirmation by her physician, ‘William S Bryan,’ that both parties agree to and understand the scope of the DNR form.

Do Not Resuscitate (DNR) Form

2. What is a DNR Form?

A Do Not Resuscitate Form, or DNR Form, is an end-of-life medical directive which instructs health care professionals to withhold life-sustaining treatment at the behest of the patient.

Patients who choose to obtain a DNR order are assured that no resuscitation methods will be performed in the event of a medical emergency — it’s important to understand what a DNR is before signing.

A DNR form is a specific document governing distinct forms of treatment and as a result there are essentially no differences between the multiple types of DNRs.

DNR forms may be known by the following names, depending on your location:

• DNAR (Do Not Attempt Resuscitation)
• AND (Allow Natural Death)
• POLST (Physician Orders for Life-Sustaining Treatment)
• MOLST (Medical Orders for Life-Sustaining Treatment)

In addition to a DNR form, the following are important estate and end-of-life planning documents:

• Last Will and Testament
• Medical Power of Attorney
• Living Will

What Does DNR Mean?

The definition of DNR in a DNR order simply stands for “do not resuscitate”.

If your heart stops beating or you stop breathing, a DNR form restricts emergency medical technicians or hospital personnel from attempting to revive you.

What Does Resuscitate Mean?

In medical terms, “resuscitate” simply refers to the various procedures used by healthcare professionals in an emergency situation to revive a person from unconsciousness or the brink of death.

In the case of a DNR order, however, “resuscitate” specifically refers to the use of cardiopulmonary resuscitation — commonly referred to as CPR.

Basic CPR techniques involve a series of chest compressions and occasional mouth-to-mouth breathing.

Advanced cardiopulmonary resuscitation (typically performed by EMS responders or trained medical personnel) involves a device known as a defibrillator, or AED. An AED delivers an electrical shock to the patient in order to reestablish a steady rhythm to their heart beat.

As a reference, resuscitation methods may include:

• Cardiac compression (or chest compressions)
• Defibrillation (electrical shock)
• Artificial ventilation (mouth-to-mouth breathing)
• Intubation (advanced airway management involving a breathing tube)

A do not resuscitate form instructs medical professionals not to use any form of CPR (basic or advanced), should you become incapacitated and require a life-sustaining procedure.

3. When is a DNR Appropriate?

End-of-life planning can be a difficult subject to address, let alone navigate. But the fact of the matter is, we all must deal with this issue at some stage of our lives. Obtaining your own DNR document should not be taken lightly — as it truly addresses life and death matters.

Scenario #1: Patients / Individuals Diagnosed with a Terminal Condition

For anyone diagnosed with a painful or terminal condition, a DNR form can help avoid prolonged suffering. Making the choice to withdraw resuscitation in the event of a cardiac or respiratory arrest does not preclude that palliative care will be withheld. That is to say, the administration of pain-relieving medication and comfort care will still be offered, should you desire.

Scenario #2: Elderly Individuals

Age is another factor that’s important to keep in mind when debating whether a DNR form is right for you. Resuscitation is an intense and oftentimes traumatic medical procedure which elderly patients may have trouble recovering from should it be successful.

Chest compressions must be applied with extreme force in order to get blood pumping through the heart. Broken ribs, bruised lungs, or even damage to the heart itself are all potential ramifications of successful CPR.

Intubation may also be used if a patient stops breathing. This invasive technique requires a tube to be rapidly inserted into the windpipe of a patient in order to manage airflow. This can lead to minor or severe complications such as damage to the esophagus and other tissue in the throat.

Scenario #3: Religious Values

Contrary to what some may think, signing a do not resuscitate order is not prohibited in the eyes of many religious institutions. With that said, each patient must consider their own personal ethics and religious values before authorizing any end-of-life planning documentation.

What Happens if a DNR is Not Followed?

In 2016, a woman in Santa Fe, New Mexico was admitted to the emergency room of a local hospital. Hospital staff attempted to resuscitate her twice — in direct violation of her do not resuscitate order.

This particular patient suffers from a rare condition which causes her immense pain and requires costly medication. As a result of this condition, she preemptively drafted a DNR form in order to avoid further expense and suffering. The hospital staff ignored her DNR form, and she filed a lawsuit shortly after the ordeal.

Signing a DNR is the same as any other legally-binding document. Once your DNR papers have been approved and filed into your medical records, they must be recognized and followed by any physician that treats you.

Additionally, your family can not override your DNR form against your will. Unless you have authorized someone to act on your behalf as your health care representative (either within the DNR itself or through a medical power of attorney), only you may choose to revoke your DNR form.

4. How to Get a DNR Form

Once you’ve decided to create your own document, there are plenty of ways for you to get a DNR form.

Our DNR form builder handles all of the necessary DNR paperwork for you. Upon completion, take your DNR medical form to your physician and have them sign it. Your doctor should then file it with the rest of your medical records.

In some instances, EMTs arriving on the scene of a medical emergency may not immediately be able to identify you or have access to your medical records on hand. Ask your doctor where you can find an official DNR bracelet which can be on your person at all times — instructing first responders how to proceed.

5. Do Not Resuscitate Laws by State

Nearly every state in America has guidelines governing do not resuscitate orders. These laws ensure patients retain a sense of control over their end-of-life planning.

The following table shows which states require signatures from patients, physicians, witnesses, a notary public, or some combination of each, in order for a DNR form to be legally valid.

Alabama	Patient and Physician	AL Code § 420-5-19-.02	Montana	Patient and 2 Witnesses	MT Code § 50-9-103
Alaska	Patient and either a Witness, Notary Public, or Physician	AK Stat 13.52.150	Nebraska	Patient and either a Notary Public or 2 Witnesses	NE Code § 20-404
Arizona	Patient, Physician, and Witness	AZ Rev Stat § 36-3251	Nevada	Patient and Attending Physician	NV Rev Stat § 450B.520
Arkansas	Patient and either a Notary Public or 2 Witnesses	AR Code § 20-13-901	New Hampshire	Patient and Attending Physician	NH Rev Stat § 137-J:26
California	Patient and Primary Physician	CA Prob Code § 4780	New Jersey	Patient and Attending Physician	NJ Admin Code § 10:48B
Colorado	Patient and Attending Physician	CO Rev Stat § 15-18.6-103	New Mexico	Patient and Physician	NM Stat § 7.27.6.8
Connecticut	Patient and Physician	CT Gen Stat § 19a-580d	New York	Patient and Physician	NY Public Health Article 29-B
Delaware	Patient and 2 Witnesses	16 DE Code § 2505	North Carolina	Patient, a Notary Public, and 2 Witnesses	NC Gen Stat § 90-321
Florida	Patient and Primary Physician	FL Stat § 401.45	North Dakota	Patient and either a Notary Public or 2 Witnesses	ND Cent Code § 23-06.5
Georgia	Patient and Attending Physician	GA Code § 31-39.6.1	Ohio	Patient and Physician	OH Admin Code § 3701-62
Hawaii	Patient and Attending Physician	HI Rev Stat § 327K-2	Oklahoma	Patient, Physician, and 2 Witnesses	OK Stat § 63-3131.5
Idaho	Patient and Physician	ID Code § 39-4514	Oregon	Patient and 2 Witnesses	OR Rev Stat § 127.810
Illinois	Patient and Witness	755 ILCS 40/65	Pennsylvania	Patient and Attending Physician	PA Con Stat Title 20 § 5484
Indiana	Patient, Physician, and 2 Witnesses	IN Code § 16-36-5	Rhode Island	Patient and 2 Witnesses	RI Gen Laws § 23-4.11
Iowa	Physician	IA Code § 144A.7A	South Carolina	Patient and Physician	SC Code § 44-78-10
Kansas	Patient and Witness	KS Stat § 65-4943	South Dakota	Patient and Attending Physician	SD Admin Rules § 44:05:06
Kentucky	Patient and Primary Physician	KY Rev Stat § 311.6225	Tennessee	Patient and Physician	TN Code § 68-11-224
Louisiana	Patient and 2 Witnesses	LA Rev Stat § 40:1151.2	Texas	Patient and either a Notary Public or 2 Witnesses	TX HSC Chapter 166
Maine	Patient and 2 Witnesses	ME Rev Stat § 5-805	Utah	Patient and Physician	UT Admin Code § R432-31
Maryland	Patient and Physician	MD Health-Gen Code § 5-608.1	Vermont	Patient and Physician	VT Stat Title 18 Chapter 231
Massachusetts	Patient and Physician	None	Virginia	Patient and Physician	VA Code § 54.1-2987.1
Michigan	Patient, Attending Physician, and 2 Witnesses	MI Comp Laws § 333.1053	Washington	Patient and 2 Witnesses	WA Rev Code § 70.245
Minnesota	Patient and either a Notary Public or 2 Witnesses	MN Stat Chapter 145C	West Virginia	Patient and Physician	WV Code § 16-30
Mississippi	Patient and Physician	MS Code § 41-41-302	Wisconsin	Patient and Physician	WI Stat § 154.17
Missouri	Patient and Attending Physician	MO Rev Stat § 190.600	Wyoming	Patient and Physician	WY Stat § 35-22-501