Do Not Resuscitate laws vary by state in five main ways: who is authorized to sign the order, which official form your state recognizes, whether witnesses or a notary are required, how emergency responders identify the order outside a hospital, and whether an order signed in one state will be honored in another. A DNR is a medical order directing healthcare providers not to perform CPR if your heart stops or you stop breathing, and because it is created under state law rather than federal law, the specific rules change when you cross a state line. One federal rule applies everywhere: any hospital, nursing facility, home health agency, or hospice that accepts Medicare or Medicaid must inform you of your right to make advance care decisions, including a DNR.
Who Can Sign a DNR
In most states, a physician (MD or DO) must sign the DNR for it to be legally valid. A growing number of states also authorize nurse practitioners or physician assistants to sign, reflecting their expanded role in primary and end-of-life care. If your regular provider is a nurse practitioner, ask whether your state lets them sign a DNR directly or whether a physician co-signature is required. A DNR that lacks the right signature is not enforceable, no matter how clearly it reflects the patient’s wishes.
The patient’s signature (or that of an authorized surrogate) is also required. Adults are presumed to have the capacity to make their own medical decisions, and that presumption holds unless a physician identifies specific reasons to question it, such as delirium, severe psychiatric symptoms, or advanced cognitive impairment. When capacity is genuinely in doubt, a formal assessment may be needed before the order can be signed.
Which Form Your State Requires
States use different standardized forms, and the names vary. You may see “out-of-hospital DNR,” “Comfort Care” order, “No CPR” order, or a state-specific POLST form. What matters is using your state’s officially recognized document. A handwritten note from your doctor, however medically clear, will not satisfy EMS protocols in most places. State health departments and hospitals provide the correct forms, usually free.
The POLST framework (Provider Orders for Life-Sustaining Treatment) illustrates how the same idea gets different names in different states. Forty-three states and Washington, D.C., have codified POLST programs into law, but the form goes by MOLST, COLST, POST, or MOST depending on the state. A POLST is broader than a DNR and covers additional treatment decisions like antibiotics, IV fluids, and hospital transfer, but the same lesson applies: use the version your state actually recognizes.
Witness and Notarization Rules
Some states require one or two witnesses when you sign a DNR. A smaller number require notarization. Witness rules commonly disqualify people who stand to inherit from you or who work at the facility providing your care, and these restrictions exist to protect against coercion. If the procedural requirements are not met, the order can be unenforceable even when everyone knew what the patient wanted. Notary fees for medical directives are generally modest, typically under $25.
Out-of-Hospital DNRs and How EMS Identifies Them
A DNR inside a hospital lives in your medical record, where staff can find it. The harder problem is at home, in public, or in transit, when someone calls 911. Emergency responders are trained to start CPR immediately, and without clear evidence of a valid DNR, that is what they will do.
Every state provides for some form of out-of-hospital DNR designed for exactly this situation. These orders typically require signatures from both the physician and the patient (or surrogate) and come with a visually distinct form, bracelet, or necklace that EMS personnel can recognize on sight. The formats vary. Some states use standardized wallet cards. Others authorize specific medallions or bracelets that meet state design specifications. A generic “DNR” bracelet ordered online may not meet your state’s requirements.
Some states treat the physical identifier itself as a valid order. Pennsylvania, for example, authorizes an out-of-hospital DNR bracelet or necklace that independently directs EMS to withhold CPR. Other states require the written form to be physically present alongside any identifier, and if the paper is not there, EMS may begin resuscitation until someone produces it. This is the point where good intentions most often collide with real-world protocols, so knowing exactly what your state requires matters.
One more detail: in some jurisdictions, out-of-hospital DNR orders expire and must be renewed by a physician. If you or a family member has a long-standing order, confirm with the provider that it is still current.
Surrogate Decision-Makers When the Patient Can’t Sign
When a patient lacks capacity to make the DNR decision, every state has rules about who can decide on their behalf. If you have named a healthcare agent through a power of attorney or advance directive, that person generally has first authority. If you have not, states fall back on a statutory priority list that commonly runs in this order: spouse or domestic partner, adult children, parents, adult siblings, then close friends. The exact order and the eligibility rules vary by state, and some states require a court-appointed guardian rather than defaulting to family.
For infants and young children, a surrogate must act in the child’s best interests rather than applying “substituted judgment,” because the child has no established preferences to substitute for.
Whether Another State Will Honor Your DNR
There is no federal law requiring states to honor another state’s DNR. Some states have reciprocity provisions or will accept an out-of-state order if it substantially complies with their own requirements. Many do not, and even the states that do often impose conditions that are hard to verify in an emergency.
If you spend significant time in more than one state (seasonal travel, extended family visits, a gradual move), the safest approach is to obtain a valid DNR in each state where you might receive care. Your physician can often help coordinate this. A POLST form may offer somewhat broader recognition among the states that have adopted the framework, but even POLST portability across state lines is not guaranteed.
At a minimum, carry your paperwork when you travel. An out-of-state order may not be legally binding, but it gives the receiving medical team strong evidence of your wishes and a basis for writing a new order quickly.
The Federal Baseline That Applies Everywhere
The Patient Self-Determination Act, in effect since 1990, requires every hospital, skilled nursing facility, home health agency, and hospice that participates in Medicare or Medicaid to give you written information about your rights under state law to accept or refuse treatment and to create advance directives, including DNR orders. The facility must document in your record whether you have an advance directive, and it cannot condition your care on whether you have signed one.1Office of the Law Revision Counsel. 42 USC 1395cc – Agreements With Providers of Services; Enrollment Processes
The implementing federal regulation adds specifics. Providers must educate their staff on advance directive policies and provide community education. If a facility has a conscience-based objection to implementing certain directives, it must disclose that limitation in writing, identify the legal authority for the objection, and describe which conditions or procedures are affected.2eCFR. 42 CFR 489.102 – Requirements for Providers
In practice, you should be asked about advance directives every time you are admitted to a hospital or enroll in a new facility. If no one asks, the facility is out of compliance, and that is a good moment to raise the subject yourself.
Pediatric DNRs and State Variation
DNR orders for children add a layer of state-by-state variation on top of what already exists for adults. Parents or legal guardians generally have broad authority to make medical decisions for their children, including end-of-life decisions.
For older adolescents, some states recognize the mature minor doctrine, which allows minors who demonstrate sufficient understanding to participate in or even control their own DNR decisions. The specific age thresholds and capacity requirements vary. Where a mature minor’s wishes conflict with the parents’ preferences, some state statutes give the minor’s wishes priority.
Schools are a separate problem. A 2005 study of 81 school districts found that only 20 percent had any policy addressing DNR orders for students, and of those, 63 percent prohibited school personnel from honoring them. The National Association of School Nurses and the American Academy of Pediatrics have supported honoring DNR orders in school settings since 2000, but many districts still lack clear protocols. If your child has a life-limiting condition and a DNR, work directly with the school administration to establish a written plan.
Changing or Revoking a DNR
Revocation is deliberately simple, and this is one area where states are largely consistent. You can revoke a DNR verbally, in writing, or by destroying the physical form. No one needs to approve the revocation. If you tell your nurse “I want CPR,” the DNR is effectively suspended immediately. Your most recent expressed wishes override earlier directives.
Modifying a DNR requires your provider to write a new order reflecting your updated preferences. Destroy the old form to avoid confusion, and tell everyone in your care circle. Confusion about which version is current is a real and recurring problem when patients move between facilities, and telling every provider and family member which version controls is the single most effective thing you can do to make sure your current wishes are followed.
What a DNR Does Not Cover
A DNR is narrow. It applies only to CPR: chest compressions, rescue breathing, defibrillation, and medications used to restart the heart. It does not tell providers to stop other treatment. You still receive pain medication, antibiotics, IV fluids, and other care appropriate to your condition. A DNR also does not address ventilators, feeding tubes, dialysis, or organ donation. Those decisions belong in a living will or, where available, a POLST form. Having both a DNR and a living will is not redundant: the DNR handles the immediate cardiac or respiratory arrest, and the living will covers the longer-arc decisions the DNR does not touch.