Frequently Asked Questions for DNR

What is Out-of-Hospital Do-Not-Resuscitate Order?

The Out-of-Hospital Do-Not-Resuscitate Order allows patients to direct health care professionals in the out-of-hospital

setting to withhold or withdraw specific life-sustaining treatments in the event of respiratory or cardiac arrest.

What is an out-of-hospital setting?

The law defines out-of-hospital as a “location in which health care professionals are called for assistance, including

long-term care facilities, in-patient hospice facilities, private homes, hospital outpatient or emergency departments,

physician’s offices and vehicles during transport.”

Who is a health care professional?

The law defines healthcare professionals as physicians, physician assistants, nurses, emergency medical services

personnel and, unless the context requires otherwise, includes hospital emergency personnel.

What life-sustaining treatments are prohibited?

Cardiopulmonary resuscitation (CPR) – Pushing down on the middle of the chest when a heart has stopped beating to

help beat the heart, and breathing into the lungs through the mouth to fill the lungs with air for a person that has

stopped breathing and whose heart has stopped beating.

Transcutaneous Cardiac Pacing – Pads put on the outside of the chest so an electrical impulse can be sent to the heart

to try to regulate certain irregular beats that could be dangerous to a person’s life.

Defibrillation – An electric shock put through the chest to try to start their heart beating again when it has stopped.

Advanced Airway Management – When trained people put what looks like a clear tube into a person’s mouth, when

that person has stopped breathing or is not able to breathe well on their own, to breathe for them.

Artificial Ventilation – When trained people use a football-sized bag and a mask that fits over a person’s mouth and

nose to push air into the lungs when the patient can’t breathe on their own or have stopped breathing.

Does this mean that there are no comfort (palliative) measures offered?

No. Comfort measures are specifically allowed.

Is the form available in Spanish or other languages?

No, but the instructions for the form are available in Spanish. Since we don’t require health professionals to speak or

read Spanish, we cannot require them to accept a form that is in Spanish. For instructions in Spanish go to

http://www.dshs.state.tx.us/emstraumasystems/dnr.shtm.

How does a competent person who cannot sign his or her name fill out a DNR form under Section A?

In the opinion of DSHS attorneys, have the person make some form or mark in Section A for signature. It does not have

to be a person’s legible name. The physicians and witnesses should be present at time of signing. On a separate sheet

of paper, write that the signature in Section A is the person’s signature and that they were competent upon signing the

Patient Statement section of the form. Have the witnesses sign and date this and attach it to the DNR form.

Does the form have to be notarized?

A notary public can witness the signature of the person filling out the form in lieu of two witnesses. If two witnesses

are present, the form does not need to be notarized.

Note: In Section D of the OOH-DNR form a notary cannot witness a competent person making an OOH-DNR order in a

non-written manner to a physician. This can only be acknowledged by two witnesses.

It says that witness one cannot provide direct patient care. Does that mean that social workers can’t sign as witness

one?

According to HHS, social workers, chaplains and people who provide nutrition services DO NOT provide direct patient

care and therefore can sign as Witness One.

Can a physician’s assistant or nurse practitioner sign the physician’s statement?

No. Only the attending physician can sign in this section.

Why does everyone have to sign twice?

All persons who have signed the DNR form must sign at the bottom of the page to acknowledge that the document has

been properly completed.

Can a DNR be revoked?

DNR can be revoked at any time by the patient or the person who acted on behalf of the agent. Revocation can be in

the form of communication to responding health care professionals, destruction of the form, or removal of devices.

Is a copy of the form acceptable?

You can make copies of the form before it’s filled out and after it’s filled out. Copies should be accepted like the

originals.

Does an image or photo on a cell phone of an entire OOH-DNR Order constitute a “copy”?

No. Chapter 166 of the Texas Health and Safety Code does not specifically allow for a cell phone image/photo to be an

acceptable substitute for a paper copy.

What happens if the patient is transported by EMS?

A copy of the form or the device must accompany the patient.

What if EMS begins treatment and is then presented with the form?

After verifying the validity and correctness of the form, EMS should cease using CPR, transcutaneous cardiac pacing,

defibrillation, advanced airway management and artificial ventilation on the patient.

What happens if the form is not filled out correctly or EMS has doubts about any of the information?

Health professionals can refuse to honor a DNR if they think:

 The patient is pregnant

 There are unnatural or suspicious circumstances surrounding the death.

 The form is not signed twice by all who need to sign it or is filled out incorrectly.

Does a person who wears a bracelet or necklace (called a device in the rules) have to also carry the form with them?

The rule states that a DNR device shall be honored in lieu of a DNR form.

What is an outpatient healthcare facility’s responsibility specifically in regards to addressing whether or not a person

has a DNR?

Health care professionals must honor a valid DNR. There is nothing in the law about a facility having to inform

patients about DNR. However, the Texas Health and Human Services (HHS), who regulates nursing homes, does have

a policy (not a rule or law) about nursing homes providing info about DNR. You might contact them at (512) 438-3161

for more information.

Is there a website that explains all this information?

The Texas Department of State Health Services Office of EMS and Trauma Systems Coordination has lots of information

about DNR, with links to the rules and statutes. For general information about DNR, a copy of the form, or names of

companies that supply the device, go to http://www.dshs.state.tx.us/emstraumasystems/dnr.shtm. For a copy of the

statute or the rules, go to https://www.dshs.texas.gov/emstraumasystems/ruldraft.shtm and scroll down to Rule

157.25. There you will find a link to the statute in the Health and Safety Code, and to DSHS’s rules.

What if I have more questions?

Call us at (512) 834-6700 or email us at the links on our website.

Filling out the Out-of-Hospital Do-Not-Resuscitate Form

Name

Fill out patient’s full legal name, date of birth and circle male/female.

Declaration

A. This box is for patients who are competent. The patient should sign his/her name, date the document, and

prints or types his/her name.

B. This box is used when the order is being completed by a legal guardian, the person with medical power of

attorney for the patient or a proxy in a directive to physician for a person who is incompetent or otherwise

mentally or physically incapable of communication. The person acting on behalf of the patient must check the

appropriate box in this section, sign and date the form and then print or type his/her name.

C. This box is used when a qualified relative is acting on behalf of an adult person who is incompetent or

incapable of communication. A qualified relative can be: (1) The patient's spouse; (2) the patient's reasonably

available adult children; (3) the patient's parents; or (4) the patient's nearest living relative. The relative acting

on behalf of the patient must check the appropriate box in this section, sign and date the form and then print or

type his/her name.

D. This box is used when a physician has evidenced that a patient has issued a previous directive to physician or

observes a person issuing an OOH-DNR by non-written communication. The physician must check the

appropriate box in this section, sign and date the form, print or type his/her name and provide his/her license

number.

E. This box is used when the order is being completed on behalf of a minor. This person can be the minor’s

parent, legal guardian or managing conservator. A physician must have diagnosed the minor as suffering from a

terminal or irreversible condition. The person acting on behalf of the minor must check the appropriate box in

this section, sign and date the form and then print or type his/her name.

F. This box is used when the order is being completed by two physicians on behalf of an adult patient who is

incompetent or unable to communicate and without a guardian, proxy or relative. The physicians must sign and

date the form, print or type their names and provide their license numbers. The second physician must not

be involved in the treatment of the patient or be a representative of the ethics or medical committee of the

health care facility in which the person is a patient. Witness or notary signatures are not required when two

physicians execute the OOH-DNR Order in this section.

Witnesses

Two witnesses or a notary public must sign that they have witnessed the patient’s signature or the signature of

a person(s) acting on the patient’s behalf in sections A-E.

A notary public can witness the signature of the person filling out the form in lieu of two witnesses.

Witness One (the “qualified” witness) may not be:

 person designated to make a treatment decision for the patient;

 related to the patient by blood or marriage;

 entitled to any part of the estate;

 be a person who has a claim against the estate of the patient;

 the attending physician or an employee of the attending physician;

 an employee of a health care facility in which the patient is being cared for, if he or she is involved in

providing direct patient care to the patient (social workers, chaplains and people who provide nutrition

services are not considered to provide direct patient care); or

 an officer, director, partner, or business office employee of a health care facility in which the patient is

being cared for or any parent organization of the health care facility.

Witness Two may be any competent adult.

Physician’s Statement

The patient’s attending physician must sign and date the form, print or type his/her name and give his/her

license number.

Signatures

The statute requires that everyone who signed the form MUST sign the form again in the bottom section to

acknowledge that the form has been completed.