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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Last Update April 9th, 2024

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Table of Contents:

What is a Do-Not-Resuscitate Order
When to Use a DNR Form
How to Get a DNR Form
How to Write a DNR Form
NDR Laws and Requirements by State
DNR Sample Form
Health and Medical Related Documents
FAQs About DNR Forms

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.

State	Signing Requirements	Law
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	§ 7.27.6.8
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.

PDF WORD

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

Long-term illness;
Terminal illness;
Alzheimer’s Disease;
Dementia

People who are extremely elderly are also those who choose to have a DNR order.

Living Will vs DNR

A Living Will may seem almost the same as a DNR order.

The difference between the 2 is a Living Will restricts a patient’s access to nourishment, food and water, or a breathing machine.

A DNR order restricts immediate intervention, such as CPR, to save someone’s life.

You are only a few steps away from your own DNR Form!

Download our professional examples

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Preview of your DNR

OUT OF HOSPITAL DO NOT RESUSCITATE ORDER
FOR
_________

ATTENTION! DO NOT MAKE ANY ATTEMPT TO RESUSCITATE THIS PATIENT!

This document represents the official request, legal in the State of Alabama, to order all medical personnel to cease any attempt to resuscitate the Patient and allow a natural death.

If you live in a state with a prehospital DNR program, it is important that you use your state's approved procedure and document. Any other document may not be honored.

A. Patient Request:

I, _________, the undersigned Patient, am competent and at least 18 years of age. I direct that resuscitative measures be withheld from me in the event of cardiopulmonary cessation. Specifically, I direct that none of the following resuscitation measures be initiated or continued for me: Cardiopulmonary resuscitation (CPR), transcutaneous cardiac pacing, defibrillation, advanced airway management, and artificial ventilation.

I have discussed this decision with my physician, and I understand the consequences of this decision.

Patient's Signature:

By: ___________________________________ Date: __________________
_________

B. Physician Authorization:

Based on the information provided, I/we direct all medical personnel, emergency responders, and paramedical personnel to refrain from performing resuscitative measures, including cardiopulmonary resuscitation, chest compression, endotracheal intubation, advanced airway management, artificial ventilation, cardiac resuscitative medications, and cardiac defibrillation, if the Patient experiences cardiopulmonary cessation.

In addition, we request that all reasonable comfort care measures be implemented, including the administration of oxygen, suction, control of bleeding, and pain medication by authorized personnel. Our goal is to alleviate the Patient's suffering and provide support to their family members, friends, and anyone else present.

Physician's Signature:

By: ___________________________________ Date: __________________

______________________________________
(print name)

Notary Acknowledgment

County of ____________________
State of Alabama

I ____________________________, a Notary Public in and for said County and State, hereby certify that ___________________________________, whose name(s) is/are signed to the foregoing instrument, and who is/are known to me (or satisfactorily proven), acknowledged before me on this day that, being informed of the contents of the instrument, she/he/they executed the same voluntarily on the day the same bears date. Given under my hand this ________ day of ________________, ________.

__________________________(Notary Public Signature)
Notary Public

My commission expires: __________________________

C. Applicability of a prehospital DNR Program:

In some states with official prehospital Do Not Resuscitate (DNR) programs, healthy individuals may not have access to these programs because they are often limited to those diagnosed with a terminal illness.

This approach stems from the fact that there are emergencies where healthy individuals may require immediate medical intervention, including CPR, without suffering long-lasting adverse effects. For example, otherwise healthy individuals may experience allergic reactions, electrical shocks, choking incidents, or cardiac arrests resulting from heart attacks, but often make a full recovery after receiving prompt emergency treatment. These situations differ from resuscitating individuals in the advanced stages of a terminal illness. Therefore, it is widely believed that prehospital DNR programs are more suitable for preventing unwanted emergency measures that prolong the dying process or increase suffering rather than applying them to healthy individuals.

However, regardless of health status or age, individuals generally retain the right to consent to or refuse medical treatment. If you hold strong beliefs about specific medical procedures, including prehospital emergency treatment, please consult with your physician or attorney. Additionally, we recommend completing a Living Will, Health Care Power of Attorney, or Health Care Advance Directive to officially document your wishes.