Table of Contents
- Do Not Resuscitate Form (PDF & MS Word)
- What is a DNR Form?
- When is a DNR Appropriate?
- How to Get a DNR Form
- Do Not Resuscitate Laws by State
1. Do Not Resuscitate Form (PDF & 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:
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 § 188.8.131.52|
|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|