Do Not Resuscitate (DNR) Orders: Forms, Signing, and Scope

A do not resuscitate order, or DNR, is a physician’s written instruction telling healthcare providers not to attempt CPR if your heart stops or you stop breathing. It covers specific interventions: chest compressions, defibrillation, insertion of a breathing tube, and connection to a ventilator. It does not touch anything else about your care.¹

What a DNR Covers and What It Does Not

A DNR activates at one specific moment: cardiac or respiratory arrest. Outside that moment, your medical care continues exactly as it would without the order. You still receive medications, antibiotics, IV fluids, surgery, oxygen for comfort, pain management, wound care, and treatment for nausea or anxiety.¹

“Do not resuscitate” is not “do not treat.” A person with a DNR who breaks a hip still gets surgery. Someone with pneumonia still gets antibiotics. This is the single most common misunderstanding in end-of-life planning, and it leads people to either avoid a DNR they want or agree to one they didn’t intend.

A related order is a Do Not Intubate, or DNI, which specifically refuses a breathing tube and ventilator. Some patients want CPR attempted but refuse mechanical ventilation. Others refuse both. Depending on how your state structures its forms, these preferences can be documented together or separately.

In-Hospital and Out-of-Hospital Forms

A DNR only works in the setting it was written for, and this catches families constantly. An in-hospital DNR is written into your chart by your physician and guides nursing staff and rapid response teams while you are admitted. It does not follow you home. It does not travel with you in an ambulance. When you are discharged, it typically requires re-evaluation.

An out-of-hospital DNR is a portable document, sometimes called a Comfort Care order or prehospital directive, designed for use anywhere outside a hospital. Every state provides some version of this form, and it is what directs paramedics and EMTs responding to a 911 call.²

Without this specific document physically present, paramedics are generally required by protocol to begin full resuscitation regardless of what family members say or what other paperwork exists. A hospital DNR sitting in your medical chart does nothing for EMS arriving at your house. Some states print the out-of-hospital form on a specific paper color so first responders can identify it quickly, and a few states recognize official DNR bracelets or medallions alongside the paper form.²

How a DNR Differs From an Advance Directive and a POLST

These three documents get mixed up, and the difference actually matters in an emergency. An advance directive is a legal document you create while healthy, describing your treatment preferences for a future when you might not be able to speak for yourself. It is not a medical order. When paramedics show up, they follow medical orders, not legal documents. Your advance directive only produces action once a physician translates it into orders in your chart.¹

A POLST form (Physician Orders for Life-Sustaining Treatment, called MOLST in some states) is a medical order like a DNR but broader. Where a DNR addresses only CPR, a POLST also covers decisions about mechanical ventilation, feeding tubes, hospitalization, and antibiotics for life-threatening infections. POLST forms are built for people who are seriously ill or have advanced frailty, and some state laws restrict physicians from signing one unless the patient meets that threshold. Forty-three states and Washington, D.C., have formally adopted POLST programs.

If you are generally healthy and want to document future preferences, an advance directive is the right tool. If you have a serious illness and want a portable medical order that goes beyond CPR, a POLST handles that. A standalone DNR sits in between: a physician order, but limited to resuscitation.

Who Can Request a DNR

Any adult with the mental capacity to make medical decisions can request a DNR for themselves. Capacity here means you can understand information about CPR, appreciate how it applies to your situation, reason through the choice, and communicate it. A poor memory or difficulty with language does not by itself prove a lack of capacity. Neither does making a decision others consider unwise.

When a patient lacks capacity, a healthcare surrogate can request a DNR on their behalf. That authority comes from one of three places: a healthcare power of attorney the patient signed while competent, a state-specific surrogate hierarchy that typically starts with a spouse and moves to adult children and then parents, or a court-appointed guardian. The surrogate is expected to follow the patient’s known wishes. If those wishes were never clearly expressed, the surrogate must act in the patient’s best interests based on the patient’s values and medical condition.

For children, additional safeguards apply. A parent or legal guardian consents, typically after the attending physician and a second physician independently confirm the child meets specific medical criteria such as a terminal condition or permanent unconsciousness. If the child is mature enough to understand and objects, most frameworks will not allow the order to proceed. Disputes between parents generally trigger a formal ethics review before an order can be issued or continued.

Getting a Valid DNR Signed

Creating a DNR starts with a conversation with your physician or, in many states, a nurse practitioner or physician assistant. Standard forms are available through your state Department of Health or directly from your provider’s office.³ The form must include your full legal name and date of birth so first responders can match the document to the right person under pressure.

Signing requirements vary by state. Every state requires signatures from the patient (or authorized surrogate) and the healthcare provider. A handful of states also require one or two witnesses, and some require notarization. Statutory maximum notary fees typically run between $2 and $15 per signature. The form must clearly state that CPR is to be withheld.

An incomplete form, a missing physician signature, or an outdated version can make the whole document unenforceable. When in doubt, medical teams default to full resuscitation. Get the form directly from your provider or state health department rather than downloading a generic template, and confirm you have the current version. Without insurance, a primary care visit runs roughly $130 to $200 nationally, though many physicians fold the DNR conversation into an existing appointment at no additional charge.

Keeping the Order Where EMS Will Find It

A DNR that no one can find is a DNR that won’t be honored. The standard recommendation is to post the original document on the front of your refrigerator or the inside of your front door. Paramedics are trained to check these locations. Your provider can also arrange for a wallet card or DNR bracelet as an immediate visual signal.³

Every person who might be present in an emergency needs to know the document exists and where it is: family members, caregivers, housemates, and your healthcare proxy. When EMS arrives, they look for the physical form, wallet card, or approved bracelet before withholding CPR. A verbal claim by a family member, without documentation, is generally not enough to override standard resuscitation protocol.

If a valid signed out-of-hospital DNR is confirmed, EMS shifts to comfort care: pain management, oxygen for breathing comfort, bleeding control, and keeping you as comfortable as possible without attempting to restart the heart.

DNRs During Surgery and Anesthesia

Surgery is where patients and families get caught off guard. If you have a DNR and need a procedure, the operating team is required to have a specific conversation with you first. Most hospitals call this “required reconsideration,” and it exists because during anesthesia, the line between a routine complication and a cardiac arrest blurs.⁴

You generally have three options during this conversation:

Full suspension of the DNR for the duration of surgery and immediate recovery, with the team using whatever resuscitation measures they judge appropriate.
Limited resuscitation by procedure, where you agree to some interventions and refuse others. You might accept defibrillation but refuse chest compressions, for example. The anesthesiologist will explain which interventions are essential to safely delivering anesthesia.
Limited resuscitation by goals, where the team uses clinical judgment based on your stated values. You might allow resuscitation for complications likely to be reversible but decline it for events likely to leave you permanently on life support.

In an emergency surgery with no time for this conversation, the standard practice is to treat the patient as if no DNR exists until an alternative provider can be identified and the patient’s wishes confirmed.⁴ Any temporary change to your DNR status during a procedure should be documented in the chart beforehand and reverted afterward.¹

Canceling or Changing a DNR

You can revoke a DNR at any time, for any reason, regardless of your physical condition. The fastest method is telling a healthcare provider or paramedic that you want to be resuscitated. A clear verbal statement overrides the written order because medical professionals must follow your most recent expressed wishes. You can also physically destroy the form.

After revoking verbally, follow up with your physician so the order comes out of your medical records. If the revocation never reaches your chart, a future medical team could find the old order and follow it. Changing your preferences rather than canceling entirely requires a new form with fresh signatures, and the old document should be destroyed to prevent confusion.

Revisit your DNR whenever your medical situation changes meaningfully. A new diagnosis, increasing frailty, a shift in prognosis, or a change in your personal values all warrant a fresh conversation.¹ If you switch doctors or move to a different care facility, the new provider should review the existing order. A revised order needs to reach everyone who holds a copy: your proxy, family, care facility, and wherever first responders would look.

When a DNR Is Ignored

The legal picture is less clean than most families assume. Historically, U.S. courts have been reluctant to award damages when a provider resuscitates a patient against a valid DNR. Families have brought claims under theories of battery, negligence, breach of contract, and constitutional violations, but for decades most courts held that prolonging life could not be treated as a compensable injury.⁵

That has begun to shift. At least one jury has awarded substantial damages in a wrongful prolongation of life case, finding a hospital and physician negligent for violating a patient’s documented wishes. These cases remain rare and the legal theories are still developing. A provider who ignores a valid DNR faces potential disciplinary action, ethics complaints, and civil litigation, but winning a lawsuit over unwanted resuscitation remains an uphill fight.

A provider who honors a valid DNR is generally protected from liability. The legal risk falls more clearly on a provider who withholds CPR without a valid order than on one who follows a properly documented directive. This is why the formalities around signatures, witnesses, and document accessibility matter. A technically deficient form gives medical teams both the obligation and the practical cover to resuscitate.

1
National Library of Medicine. Do Not Resuscitate – StatPearls
2
Merck Manuals. Do-Not-Resuscitate (DNR) Orders
3
MedlinePlus. Do-not-Resuscitate Order
4
National Library of Medicine. Do Not Resuscitate, Anesthesia, and Perioperative Care
5
PubMed. What Are the Consequences of Disregarding a Do Not Resuscitate Directive in the United States