Free DNR Form
Use our Do-Not-Resuscitate order template to list treatments you want to be withheld if you don’t want life-saving intervention. Outline your health preferences and decisions in your DNR form.
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What is a Do-Not-Resuscitate Order
A Do-Not-Resuscitate order or DNR order is a legal document that is used by patients who are terminally ill.
It is fairly common among people who have an illness or condition that cannot be cured and will almost certainly lead to death. It is also common among elderly people.
The purpose of a DNR order is to request not to be brought back to life by any means, for example, by CPR.
Although it’s usually the same throughout the country, some states have specific requirements for this document.
When to Use a DNR Form
A DNR form is something you have to plan in advance.
However, you may be wondering, at what moment does someone need it?
There are situations when someone requires aggressive treatment to continue living. Especially those who are terminally ill.
Depending on your personal preferences and circumstances, you might feel that it’s better to simply pass on peacefully.
For instance, you may not want to be brought back to life when:
There is no benefit to your health: CPR, for instance, is not intended for people who are terminally ill. The treatment most likely wouldn’t be successful.
A loss of quality of life: The life-saving measures may save you. However, there is a good chance you survive with severe harm to your organs. This means you would be dependent on a machine to breathe and stay alive.
Already close to death: Instead of a forceful intervention, a peaceful death might seem like the better option.
How to Get a DNR Form
If you feel that it would be a good idea to create your own Do-Not-Resuscitate order, then you have to follow some steps.
At first, you might not be sure how to obtain a DNR form.
LawDistrict makes it a much easier process thanks to our printable documents and guidance.
Once you have your form, follow these steps to formalize your order.
Speak with your (or a)physician: For a DNR form to be activated, it requires a doctor’s signature. The doctor confirms that you as the patient are sane enough to come to this decision. The doctor confirms you are signing the document voluntarily.
Choose possible medical treatments: The main treatment a DNR form covers is CPR treatment. You have the right to accept or refuse other treatments, such as chemo or breathing machines. You can finalize these requests in a Living Will.
Get formed signed: Different states have different requirements. However, in general, you will need to sign the DNR order in front of two witnesses and a doctor.
Receive DNR Bracelet: Patients that choose to complete a DNR form often get a bracelet or other type of accessory. This notifies doctors to follow DNR requests.
How to Write a DNR Form
There are very important details and information that must be included in a DNR form.
Follow these steps to know exactly what you need to write on the document.
Write the name of the patient and then state where you or that person lives.
Make sure to make the requests known, that CPR, or another treatment, is to be withheld.
Acknowledgement: The people who are in charge of the patient must sign the document. Signing means they acknowledge and support the preferences.
Attorney-in-fact Consent: Choose an Attorney-in-Fact.
Surrogate Consent: The Health Care Surrogate directs treatment based on what the patient would have wanted. He or she must sign.
Authorization from a Medical Doctor: A physician signs this part. It directs any medical personnel to stop treatments that could save the patient’s life.
Witnesses and/or Notary Public: Declare that everyone signing the document is of sound mind. Then they must also sign.
NDR Laws and Requirements by State
As with many legal documents, NDR forms have different requirements to meet according to their state.
Have a look at the table and see what your state signing requirements are.
|Alabama||Patient and Medical Doctor||§ 420-5-19-.02|
|Alaska||Patient and Medical Doctor||§ AS 13.52.150|
|Arizona||Patient, Medical Doctor, and Witness||§ 36-3251|
|Arkansas||Patient and Medical Doctor||§ 20-13|
|California||Patient and Medical Doctor||§ 4780|
|Colorado||Patient and Medical Doctor||§ 15-18.6-102|
|Connecticut||Patient and Medical Doctor||§ 19a-580d|
|Delaware||Patient and Medical Doctor||§ 2509A|
|Florida||Patient and Medical Doctor||§ 64J-2.018|
|Georgia||Medical Doctor||§ 31-39-(2-9)|
|Hawaii||Patient and Medical Doctor||§ 327K-2|
|Idaho||Patient and Medical Doctor||§ 39-4514|
|Illinois||Patient, Medical Doctor, and Witness||§ 755 ILCS 40/65|
|Indiana||Patient, Medical Doctor, and two Witnesses||§ 16-36-5|
|Iowa||Medical Doctor||§ 144A.7A|
|Kansas||Patient, Medical Doctor, and Witness||§ 65-4943|
|Kentucky||Patient, and two Witnesses or Notary Public||§ 311.623|
|Louisiana||Patient and Medical Doctor||§ 40:1155.3|
|Maine||Patient and Medical Doctor||§ 93-A.1(b)|
|Maryland||Medical Doctor||§ 5-608.1|
|Massachusetts||Patient and Medical Doctor||None|
|Michigan||Patient, Medical Doctor and two Witnesses||§ 333.1053|
|Minnesota||Patient and Medical Doctor||§ Chapter 145C|
|Mississippi||Patient and Medical Doctor||§ 41-41-302|
|Missouri||Patient and Medical Doctor||§ 190.603|
|Montana||Patient and Medical Doctor||§ 37:10|
|Nebraska||Patient, M.D. and Witness/ Patient and Two Witnesses for Declaration||§ 20-404|
|Nevada||Patient and Medical Doctor||§ 450B.520|
|New Hampshire||Patient and Medical Doctor||§ 137-J:26|
|New Jersey||Patient and Medical Doctor||N.J.A.C. 10:48B|
|New Mexico||Patient and Medical Doctor||§ 18.104.22.168|
|New York||Patient and Medical Doctor||§ Senate Bill S7883|
|North Carolina||Patient, Two Witnesses and Notary Public for Declaration||§ 90-321 & § 90-322|
|North Dakota||Patient and Medical Doctor for POLST||§ 23-06.5|
|Ohio||Medical Doctor||§ 3701-62|
|Oklahoma||Patient, Medical Doctor, and Two Witnesses||§ 63-3131.5|
|Oregon||Medical Doctor for POLST||§ 847-035-0030(6) & § 847-010-0110|
|Pennsylvania||Patient and Medical Doctor||§ 5481 – § 5488|
|Rhode Island||Patient and Medical Doctor||§ R23-4.11-MOLST|
|South Carolina||Patient and Medical Doctor||§ 44-78-10 – § 44-78-65|
|South Dakota||Patient and Medical Doctor||§ ARSD 44:05:06 & SDCL 34-12F|
|Tennessee||Patient and Medical Doctor for POST||§ 68-11-224|
|Texas||Patient, Medical Doctor and either Two Witnesses or 2nd M.D.||§ 157.25 & Chapter 166|
|Utah||Patient and Medical Doctor||§ R432-31|
|Vermont||Patient and Medical Doctor||§ 9708 & § 9709|
|Virginia||Patient and Medical Doctor||§ 54.1-2987.1|
|Washington||Patient and Medical Doctor for POLST||§ 43.70.480 & § 70.245|
|West Virginia||Patient and Medical Doctor for POLST||§ 16-30C|
|Wisconsin||Patient and Medical Doctor||§ 154.17 – § 154.29|
|Wyoming||Patient and Medical Doctor||§ 35-22-501 – 35-22-509|
DNR Sample Form
Even if you have all the information available to make your DNR order form, it is a good idea to have a look at a sample before you make your own. LawDistrict provides a printable DNR form for you to see and use as a template.
FAQs About DNR Forms
If you are still left with doubts about Do-Not-Resuscitate orders, we can clear those up for you.
Below, the most common questions regarding DNR orders are answered.
How to Revoke a Do-Not-Resuscitate Order
Firstly, if you ever would like to revoke your DNR order, you should speak with your physician.
Secondly, you then should eliminate any DNR documents and accessories, such as the DNR bracelet.
These could be found by medical staff, and they might continue with the DNR order.
Who Needs a DNR Form?
There are very specific people who might want a DNR form. For example, people who have been suffering from an illness for a very long time.
The list of people who would choose a DNR order are usually suffering from
People who are extremely elderly are also those who choose to have a DNR order.
You are only a few steps away from your own DNR Form!