Do Not Resuscitate (DNR) Order

A Do Not Resuscitate (DNR) Order in the United States records a person's instructions for their future medical care should they lose capacity to decide.

DNR Orders are authorized under state law in all 50 US states and the District of Columbia, though the specific statutory and regulatory requirements vary significantly by state. California Health and Safety Code §§ 7185-7195 (the Natural Death Act) and § 24172 govern DNR orders and related advance directives in California. Texas Health and Safety Code §§ 166.001-166.166 (the Advance Directives Act) governs DNR orders and out-of-hospital DNR (OOH-DNR) orders in Texas. New York Public Health Law §§ 2960-2979 (the Health Care Proxy Law and DNR Order Law) governs DNR orders in New York hospitals and other healthcare facilities.

A DNR Order is distinct from several related but different advance care planning documents. A Living Will (also called an Advance Directive or Directive to Physicians) is a document in which a person expresses their preferences regarding life-sustaining treatment in advance, while they still have decision-making capacity, for use if they later lose capacity. A Living Will is not a medical order; it is a statement of preferences that must be translated into a medical order by a physician to have immediate clinical effect. A Healthcare Power of Attorney (HCPOA) or Healthcare Proxy designates a person (the healthcare agent or proxy) to make medical decisions on behalf of the patient when the patient cannot make decisions themselves.

A Physician Orders for Life-Sustaining Treatment (POLST) form — called MOLST in New York and Maryland, MOST in North Carolina, DNAR in other states, and by other names in different jurisdictions — is the most complete physician order form for end-of-life care preferences. Unlike a DNR Order (which covers only CPR), a POLST form addresses multiple treatment decisions including CPR, level of medical intervention (comfort-focused vs. limited intervention vs. full treatment), artificial nutrition and hydration, and hospitalization preferences. POLST forms are portable medical orders designed to accompany patients across care settings — from home to hospital to nursing facility to hospice.

The Joint Commission (TJC), which accredits hospitals and health systems in the United States, requires accredited facilities to maintain policies and procedures addressing the use of DNR orders and to confirm that patient preferences regarding resuscitation are documented in the medical record and honored by clinical staff. The American Heart Association (AHA), the American Medical Association (AMA), and the Society of Critical Care Medicine (SCCM) have published clinical guidelines on the use of DNR orders and shared decision-making processes for end-of-life care.

A US DNR Order is needed whenever a patient — or their authorized surrogate decision-maker — has made an informed decision, in consultation with their attending physician, that the burdens of CPR outweigh the potential benefits given the patient's medical condition, prognosis, and values.

For patients with terminal illness — advanced cancer, end-stage heart failure, end-stage COPD, end-stage renal disease, or advanced dementia — a DNR Order is part of a complete goals-of-care conversation initiated by the attending physician, oncologist, cardiologist, or palliative care specialist. The American Society of Clinical Oncology (ASCO) recommends that oncologists initiate goals-of-care discussions, including the question of resuscitation preferences, with patients with advanced cancer within 3 months of diagnosis. Palliative care programs at major academic medical centers including the Mayo Clinic, Johns Hopkins Hospital, Massachusetts General Hospital, and MD Anderson Cancer Center integrate DNR order discussions into their standard care protocols.

For elderly patients in nursing facilities — skilled nursing facilities (SNFs) and long-term care facilities governed by the Centers for Medicare & Medicaid Services (CMS) under 42 CFR Part 483 — a DNR Order may be appropriate if the patient has experienced multiple hospitalizations for CPR that did not improve their functional status or quality of life. CMS requires that nursing facilities provide residents with information about their right to formulate advance directives including DNR orders.

For patients admitted to hospital intensive care units (ICUs) with serious illness, trauma, or post-surgical complications, attending physicians in critical care medicine initiate discussions about resuscitation preferences as part of family meetings. These discussions are guided by clinical ethics consultation services available at hospitals accredited by The Joint Commission.

An out-of-hospital DNR (OOH-DNR) order is needed for patients who want their DNR preferences honored outside the hospital — at home, in a nursing facility, in a residential care facility, or in any setting where emergency medical services (EMS) may respond. Standard hospital DNR orders are not automatically honored by paramedics and EMTs responding to 911 calls; a separate out-of-hospital DNR order in the format required by the applicable state's EMS regulations is required. Texas Health and Safety Code § 166.082, California Health and Safety Code § 24172, and New York Public Health Law § 2977-a each establish specific forms and procedures for out-of-hospital DNR orders.

For patients who have previously completed a POLST/MOLST form specifying that they do not want CPR, a separate DNR Order may be executed in the hospital to confirm that the resuscitation preference is prominently documented in the medical record and on any resuscitation alert systems used by the hospital's rapid response team.

A valid US DNR Order must contain specific elements required by the applicable state's law and the policies of the healthcare facility in which it is issued. The following provisions are standard across all jurisdictions.

The patient identification section includes the patient's full legal name, date of birth, medical record number (MRN), and the name of the healthcare facility where the order is issued. For out-of-hospital DNR orders in Texas, California, and most other states, the patient's date of birth and the attending physician's DEA or state medical license number must appear on the order form. Accurate patient identification is critical: a DNR order applied to the wrong patient due to a documentation error is a serious medical error subject to Joint Commission reporting requirements.

The scope of the DNR order section clearly states that the order instructs all healthcare providers not to initiate cardiopulmonary resuscitation — including chest compressions, electrical defibrillation, endotracheal intubation for resuscitation purposes, and cardiotonic medications — in the event of cardiac or respiratory arrest. The scope statement should confirm that all other forms of medical treatment continue unless limited by a separate order, to prevent misunderstanding that a DNR order encompasses a broader withdrawal of care than it actually does.

The decision-maker identification section identifies who authorized the DNR order: the patient (if the patient has decision-making capacity, defined as the ability to understand information, appreciate consequences, reason about options, and communicate a choice) or the patient's authorized surrogate decision-maker (healthcare agent under a Healthcare Power of Attorney, court-appointed guardian, or statutory surrogate under state law's priority hierarchy). The basis for the surrogate's authority — the document granting authority, or the statutory priority applicable in the state — should be noted.

The attending physician signature section bears the original signature of the attending physician, the date and time of signing, and the physician's name printed or stamped. In California, Texas, New York, and most other states, a DNR order must be signed by a licensed physician (MD or DO) to be valid; in some states, nurse practitioners (NPs) and physician assistants (PAs) with prescriptive authority may sign DNR orders under applicable state scope-of-practice statutes. The physician's signature confirms that the order was issued after an appropriate informed consent discussion with the patient or surrogate.

For out-of-hospital DNR orders in states that use state-specific standardized forms — Texas OOHDO (Out-of-Hospital Do-Not-Resuscitate Order), California POLST form, New York's Nonhospital DNR Order form — the form must match the state-approved format exactly. Texas EMS protocols require paramedics to honor a Texas OOHDO bearing the patient's or legal representative's signature and the attending physician's signature, but not a hospital DNR order or a non-Texas form.

The revocation provision confirms that the DNR order may be revoked at any time by the patient with decision-making capacity, or by the authorized surrogate if the patient lacks capacity, and specifies the mechanism for revocation — verbal or written communication to any healthcare provider, who must immediately notify the attending physician and update the medical record.