Facing a serious or life-limiting illness often means making difficult decisions about future medical care. While these conversations aren’t easy, planning ahead can provide you with the peace of mind that your healthcare wishes are documented, understood, and respected. A Do Not Resuscitate (DNR) order is a special form that allows patients to record these difficult decisions in advance so their healthcare providers and loved ones have clear guidance if an emergency arises.
WordLayouts provides an editable & customizable DNR order form template that includes all important information to create comprehensive and compliant paperwork. Access this template to clearly and accurately document all important decisions.
What Is a DNR Order Form?
A DNR order form is an official directive for healthcare providers to let them know about the patient’s decision not to be revived using resuscitation treatments.
The resuscitation treatments include CPR (cardiopulmonary resuscitation), defibrillation, intubation, chest compressions, assisted ventilation, and endotracheal intubation. This form is commonly used by patients with a terminal illness, poor prognosis, or older individuals with a low survival chance. Documenting these decisions in advance helps ensure that a person’s treatment preferences are respected if they are no longer able to communicate.
Moreover, there are two different types of DNR orders that are used in different healthcare settings. An in-hospital DNR applies only while a patient is admitted to a hospital. An out-of-hospital DNR applies in settings such as a private residence, a nursing home, or during emergency medical transport. Because each state has its own rules and forms, the requirements for these orders can vary.
It is important to remember that a DNR form does not mean “No treatment.” Patients can still receive all other non-invasive medical care, including medications, oxygen, pain relief, and comfort-focused treatments. It only applies to resuscitative measures in the event of cardiac or respiratory arrest.
Here, it is also important to note that for a DNR order to be valid in a medical setting, it must be completed and signed in accordance with applicable state law and local requirements.
What This Template Includes
To make it easier to understand and complete, the template is divided into nine sections:
Patient’s statement
This section declares a patient’s decision not to receive resuscitative treatments or advanced cardiac life support medications.
It also confirms that the person understands the medical implications of the decision while asking physicians, family members, caregivers, and medical personnel to respect and honor their will.
Lastly, it makes clear that the patient is not permanently locked into this decision and can revoke or modify it at any time.
Advance directives/living will
This part is for authorized representatives when a patient is unable to make healthcare decisions. It confirms the patient’s decision not to seek resuscitative treatments is based on a Living Will or Advance Directive completed when the patient was capable of making decisions. The representative confirms that such a document exists and that the DNR order reflects the patient’s previously expressed wishes.
The main purpose of this section is to confirm that the representative’s decision and the DNR order align with the patient’s prior instructions. A legally authorized representative can be a healthcare proxy, a person with the patient’s medical power of attorney, or any recognized decision-maker under applicable state law.
Living will vs DNR order
A DNR order and a Living Will both deal with advance care and end-of-life planning. However, they work in different contexts and have different levels of authority.
A DNR order is an instruction for healthcare providers not to give resuscitative measures in the event of cardiac or respiratory arrest. It is typically signed or authorized by a physician and is intended for immediate clinical use in emergencies.
On the other hand, a living will has a broader scope. It records a person’s preferences about medical treatments such as ventilators, surgery, feeding tubes, or life support. While a DNR is limited only to emergencies, a living will form is not limited to emergencies. It is used for decision-making over a wider range of medical situations when the person cannot communicate.
Keep in mind that a living will form or any advance directive can not automatically function as a DNR order. Under a living will, healthcare providers can still perform CPR unless a valid DNR is in place.
Medical power of attorney consent
This section confirms the legal authority of the individual acting as the patient’s authorized representative. It applies when the patient has appointed someone through a Medical Power of Attorney (MPOA) to make healthcare decisions on their behalf. This includes an MPOA agent or another legally recognized decision-maker. The appointed agent signs this section to authorize the DNR order in accordance with the authority granted under the MPOA.
An MPOA agent is a person legally appointed by the patient to make medical decisions on their behalf. The section also documents the representative’s consent to withhold resuscitative measures in cases of cardiac or respiratory arrest. The representative may be required to provide documentation verifying their authority.
Surrogate consent
The next section is for surrogate consent. It allows a legally authorized surrogate to make DNR order decisions on behalf of the patient.
A surrogate is a person recognized by law or medical policy to make healthcare decisions on behalf of a patient when they haven’t chosen an MPOA. A surrogate has to ensure that the decision reflects the patient’s preferences.
Legal guardian statement (if applicable)
This section is specially included for parents and legal guardians to make life-restoration treatment decisions for minors. It verifies their authority, confirms their consent, and acknowledges their understanding of the implications of a DNR order.
Lastly, it states that the legal guardian’s decision is not permanent and can be changed or revoked at any time.
Physician authorization
This part requires the attending physician to assess and acknowledge that the patient or their legally authorized agent willingly made the DNR decision, with full knowledge of the consequences.
It authorizes healthcare providers to withhold resuscitative measures. At the same time, the physician will make sure that the patient gets all appropriate comfort care. The physician’s signature validates that the order was correctly documented and entered into the patient’s medical record for implementation by healthcare professionals.
Witness(es) statement
A witness statement is added to verify that the document is signed voluntarily and the patient or representative appears to be of sound mind. The template includes space for two witnesses. If you want to add more, you can simply edit.
Moreover, witness statements are only considered if they are 18 years of age or older. The section also includes a declaration that witnesses don’t have any financial or other interest in the execution of this order.
Notary acknowledgment (if applicable)
The template also provides space for notarization to formally verify the identity of the patient. However, notarization requirements can vary by state, and some healthcare facilities may have additional documentation or administrative policies. In many cases, a DNR order becomes valid with physician authorization, while notarization may be optional or required for related documents.
Authorized officer acknowledgment (if applicable)
The last part allows an authorized official, such as in military or institutional settings, to verify the document where a civilian notary is not available.
How to Get a DNR Order
Getting a DNR order involves a few important steps. Each step helps make your medical preferences properly understood and documented.
There are four key steps involved in preparing your DNR order:
- Discuss with your physician. It is important to discuss your medical condition with the doctor to get a complete picture before making a decision. Your physician, who is handling your case, can guide you better about the chances of survival.
- Decide on your future course of treatment. Make one thing clear in your mind: having a DNR order doesn’t deprive you of your right to get good treatment. You can still discuss non-invasive methods and appropriate treatment for your illness. However, things can become problematic if the patient is unconscious or unable to speak with medical personnel or family members. The best approach is to formalize these more detailed care directives in a living will or advance directive.
- Complete and sign the form. After finalizing, get it reviewed by a doctor and sign the form in the presence of witnesses (if applicable).
- Keep it safe. After signing, keep a copy and also give a copy to your doctor and hospital so they have a copy in their medical records. This can reduce the risks of confusion.
Some people even carry portable DNR identifiers rather than paper forms so their wishes are more likely to be recognized outside of a hospital setting. These may include bracelets, necklaces, or wallet cards that notify emergency personnel about the existence of a DNR order. However, these items do not replace a properly executed DNR order. Many states encourage emergency responders to verify a physician-authorized DNR order before withholding CPR. Carrying a portable identifier together with the appropriate documentation can help ensure that your wishes are recognized and followed.
Will signing the DNR order affect my health insurance coverage?
No. A DNR is a medical directive that applies only to resuscitative measures, and it does not interfere with routine medical care. It is not part of your insurance policy, and your insurer is not a party to it. If you have questions about how a DNR may relate to your specific insurance coverage, check with your insurer.
How to revoke a DNR?
To revoke your DNR order, tell your attending physician. Under this form, the physician must promptly document the revocation in your medical record. If you are unable to communicate your wishes, a health care agent can do so for you. Only the patient or the patient’s legally authorized representative, such as a healthcare agent, surrogate, parent, or legal guardian, can revoke a DNR.
Summary
This DNR form template is designed to help you document your medical decisions clearly and in an organized format. It includes sections for patient information, authorized representatives, physician authorization, witnesses, and other supporting acknowledgments where applicable. Available in Microsoft Word and Google Docs, it can be easily customized to meet your individual needs and comply with applicable state requirements.
