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

Figure: 25 TAC §157.25 (h)(2)

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OUT-OF-HOSPITAL DNR INSTRUCTIONS

PURPOSE:

This form was designed to comply with the requirements as set forth in Chapter 166 of the Health and Safety Code (H&SC) relating to the issuance of

Out-of-Hospital Do-Not-Resuscitate (DNR) orders for the purpose of instructing Emergency Medical Personnel and other health care professionals to

forgo resuscitation attempts and to permit the patient to have a natural death with peace and dignity. This order does NOT affect the provision of other

emergency care including comfort care.

APPLICABILITY:

This form applies to all health care professionals operating in any out-of-hospital setting to include hospital outpatient or emergency departments and

physician’s offices.

IMPLEMENTATION:

A competent adult may execute or issue an Out-of-Hospital DNR Order. The patient’s attending physician will document the existence of the

directive in the patient’s permanent medical record.

If an adult patient is capable of providing informed consent for the order, he/she will sign and date the out-of-hospital DNR order on the front of this

sheet in Box A. In the event that an adult patient is unable to provide informed consent, his/her Legal Guardian, agent under Medical Power of

Attorney, or Qualified Relative may execute the order by signing and dating the form in Box B. If an adult patient is unable to provide informed

consent and none of the persons listed in Box B are available, the treating physician may execute the order using Box D with the consent of a second

physician who is not treating the patient and/or is a member of the health care facility ethics committee or other medical committee.

The following persons may execute an out-of-hospital DNR order on behalf of a minor: the minor’s parents, the minor’s legal guardian or the minor’s

managing conservator. A person executing a DNR order on behalf of a minor may execute the order by signing and dating the form in Box C. An out-

of-hospital DNR order may not be executed unless the minor has been diagnosed by a physician as suffering from a terminal or

irreversible condition.

The form must be signed and dated by two witnesses except when executed by two physicians only (Box D).

The original standard Texas Out-of-Hospital DNR form must be completed and properly executed. Duplicates may be made by the patient, health care

provider organization or attending physician as necessary. Copies of this completed document may be used for any purpose that the original

may be used and shall be honored by responding health care professionals.

The presence of a Texas DNR identification device on a person is sufficient evidence that the individual has a valid Out-of-Hospital DNR Order.

Therefore, either the original standard form, a copy of the completed standard form, or the device is sufficient evidence of the existence of the order.

For information on ordering identification devices or additional forms, contact the Texas Department of State Health Services at (512) 834-6700.

REVOCATION:

The Out-of-Hospital Do-Not-Resuscitate Order may be revoked at ANY time by the patient OR the patient’s Legal Guardian/Agent/Managing Conser-

vator/Qualified Relative, Parent (if a minor), or physician who executed the order. The revocation may involve the communication of wishes to

responding health care professionals, destruction of the form, or removal of all or any Do-Not-Resuscitate identification devices the patient may possess.

AUTOMATIC REVOCATION: This Out-of-Hospital DNR order is automatically revoked if the patient is known to be pregnant or in the case of

unnatural or suspicious circumstances.

DEFINITIONS:

Attending Physician: The physician who is selected by or assigned to a patient who has primary responsibility for a person’s treatment and care and

is licensed by the Texas State Board of Medical Examiners or who is properly credentialed and holds a commission in the uniformed services of the United

States and who is serving on active duty in this state. (H&SC 166.002 (3) & (12))

Qualified Relatives: Those persons authorized to execute or issue an out-of-hospital DNR order on behalf of a person who is comatose, incompetent,

or otherwise mentally or physically incapable of communication under Section 166.088 H&SC Section 166.088 refers to 166.039; “One person, if

available, from one of the following categories, in the following priority...: (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.”

Health Care Professional: Means physicians, nurses, physician assistants and emergency medical services personnel, and, unless the context requires

otherwise, includes hospital emergency department personnel. (H&SC 166.081 (5))

Witnesses: Two competent adult witnesses must sign the form acknowledging the signature of the patient or the person(s) acting on the patient’s behalf

(except when signed by two physicians in Section C). Witness One must meet the qualifications listed below. Witness Two may be any competent adult.

Witness One (the “qualified” witness) may not be: (1) person designated to make a treatment decision for the patient; (2) related to the patient by blood

or marriage; (3) entitled to any part of the estate; (4) be a person who has a claim against the estate of the patient; (5) the attending physician or an

employee of the attending physician; (6) 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; or (7) 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.

Please report any problems with this form to the Texas Department of State Health Services at (512) 834-6700.

Revised July 19, 2005

Texas Department of State Health Services

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Publications No. EF01-11421