Standard Out-Of-Hospital Do-Not-Resuscitate Order

Figure: 25 TAC §157.25 (h)(2)

Page 1 of 2

TEXAS DEPARTMENT OF STATE HEALTH SERVICES

DO NOT

STANDARD

OUT-OF-HOSPITAL DO-NOT-RESUSCITATE ORDER

STOP

RESUSCITATE

This document becomes effective immediately on the date of execution. It remains in effect until the patient is pronounced dead by

authorized medical or legal authority or the document is revoked. Comfort measures will be given as needed.

All persons who sign the form must sign again under number 3.

Date of Birth:

Male/Female

(Circle One)

Patient’s full legal name — printed or typed

COMPLETE ONE OF THE FOUR BOXES: A, B, C, or D. If using Box A, B, or C, Witnesses and Physician’s Statement must be completed.

Patient’s Statement: I, the undersigned, am an adult capable of making an informed decision regarding the withholding or withdrawing of

CPR, including the treatments listed below, and I direct that none of the following resuscitation measures be initiated or continued:

Cardiopulmonary Resuscitation (CPR), Transcutaneous Cardiac Pacing, Defibrillation, Advanced Airway Management,

Artificial Ventilation.

Signature

Date

Printed or Typed Name

Only use this box if the order is being completed by a person acting on behalf of an adult patient who is incompetent or

otherwise unable to make his or her wishes known.

I am the patient’s: c legal guardian; c agent under Medical Power of Attorney; c or Qualified Relative (see back); AND:

c I attest to issuance of an Out-of-Hospital DNR by the patient by nonwritten means of communication; O R

c I am acting under the guidance of a prior Directive to Physicians; O R

c I am acting upon the known values and desires of the patient; O R

c I am acting in the patient’s best interest based upon the guidance given by the patient’s physician.

I direct that none of the following resuscitation measures be initiated or continued on behalf of the patient: Cardiopulmo-

nary Resuscitation (CPR), Transcutaneous Cardiac Pacing, Defibrillation, Advanced Airway Management, Artificial

Ventilation.

Signature

Date

Printed or Typed Name

Only use this box if the order is being completed by a person acting on behalf of a minor patient who has been diagnosed

with a terminal or irreversible condition.

I am the minor patient’s: c Parent; c legal guardian; or c managing conservator.

I direct that none of the following resuscitation measures be initiated or continued on behalf of the patient: Cardiopulmo-

nary Resuscitation (CPR), Transcutaneous Cardiac Pacing, Defibrillation, Advanced Airway Management, Artificial Ventilation.

Signature

Date

Printed or Typed Name

WITNESSES: (see qualifications on reverse) We have witnessed all of the above signatures.

Witness 1 Signature

Date

Witness Printed or Typed Name

Witness 2 Signature

Date

Witness Printed or Typed Name

PHYSICIAN’S STATEMENT: I, the undersigned, am the attending physician of the patient named above. I have noted the existence of this order in

the patient’s medical records, and I direct out-of-hospital health care professionals to comply with this order as presented.

Date

Physician’s signature

Printed name

License number

Only use this box if the order is being completed by two physicians acting on behalf of an adult who is incompetent or

otherwise unable to make his or her wishes known, and who is without a legal guardian, agent, or qualified relative .

c I attest to issuance of an Out-of Hospital DNR by the patient by nonwritten communication; O R:

c The patient’s specific wishes are unknown, but resuscitation measures are, in reasonable medical judgement, considered ineffective in

these circumstances or are otherwise not in the best interest of the patient.

I direct that none of the following resuscitation measures be initiated or continued on behalf of the patient: Cardiopulmo-

nary Resuscitation (CPR), Transcutaneous Cardiac Pacing, Defibrillation, Advanced Airway Management, Artificial Ventilation.

Signature

Treating Physician

Date

Printed or Typed Name

Signature Second Physician who is not involved in treating the patient

Date

Printed or Typed Name

ALL PERSONS WHO SIGNED MUST SIGN HERE (Pursuant to H&SC 166.083(b)(13). This document has been properly completed.

Signature of Patient, Agent or Relative (A, B, or C)

Signature of Second Physician (D)

Signature of Attending Physician

Signature of Witness

Date

SHOULD TRANSPORT OCCUR, THIS DOCUMENT OR A COPY MUST ACCOMPANY THE PATIENT

Standard Out-Of-Hospital Do-Not-Resuscitate Order - Texas

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