Do Not Resuscitate
Desire of Patient Supersedes Out-of-Hospital DNR Order
Various individuals can revoke a DNR order at any time. These include the patient (including a competent minor)
or a person who identifies himself or herself as the legal guardian, a qualified relative, or having a medical power
of attorney. Revocation can be in the form of communication to responding health care professionals, destruction
of the form, or removal of devices.
Qualified relatives are defined in the following priority; the patient’s
- Reasonably available adult children;
- Parents; or
- Nearest living relative.
Identifying DNR Order Devices and Determining their Validity
EMS personnel will accept any one of the following devices as proof of a valid DNR order. EMS personnel are
not required to accept or interpret an out-of-hospital DNR order that does not meet the requirements of this policy.
If doubt exists as to whether the DNR Order Form presented is valid, EMS personnel will initiate resuscitation until
discovery of a valid DNR order or transfer of patient care to a higher level. DNR requests that do not meet the
approved form outlined in this policy (including requests by a Medical Power of Attorney) require BioTel
DNR Order Form
The official Texas Department of State Health Services Out-of-Hospital Do-Not-Resuscitate Form is an original,
single page form with a Texas DNR logo in the upper, left-hand corner of the page. Duplicate copies are valid.
Consider the form valid if the following conditions exist:
- The patient’s identity matches that of the patient named on the form.
- The form is the original TDSHS Form containing the DNR logo or a copy.
- All required sections are completed.
- All required signatures are present.
There are two acceptable DNR bracelets. The first is a white, plastic, hospital-type bracelets with the word
“TEXAS” (or a representation of the geographical shape of Texas and the word “STOP” imposed over the shape
and the words “DO NOT RESUSCITATE”. The bracelet contains no other identifying information. The other type
of DNR bracelet is made of stainless steel, looks similar to the “medic alert” bracelets, and is inscribed with the
words “TEXAS DO NOT RESUSCITATE – OOH.
EMS personnel will honor either bracelet around the patient’s wrist as if it were a valid DNR Order Form. You
cannot honor a DNR bracelet unless the patient is wearing it around the wrist. Do not remove the bracelet from
the patient, even when the patient is deceased.
The DNR necklace is made of a stainless steel chain, 16 to 18 inches in length with a one-inch diameter disk
attached. Inscribed on the disk is the same information as is found on the metal bracelet. EMS personnel will
honor this necklace worn around the patient’s neck as if presented with a valid paper DNR Order form.
Out-of-State DNR Orders
EMS personnel may accept a paper Out-of-Hospital DNR form that the patient executed in another state, as long
as the order appears valid and there is no reason to question the authenticity of the order. EMS personnel may
not accept any bracelets, necklaces, or other similar devices as proof of Out-of-State DNR Orders.
Do Not Honor A DNR Order form if:
- There is alteration in the meaning of the form, e.g., some of the listed treatments are marked through as if
to reject them.
- The patient communicates a desire to revoke the order.
- Revoked by the attending physician, legal guardian, a close relative (spouse, child, parent, or nearest living relative), or the person who has proxy or Durable Power of Attorney for Health Care.
- The patient is pregnant.
- You cannot conclusively match the name on the form to the identity of the patient.
- Unnatural or suspicious circumstances are present.
Compliance with Out-of-Hospital DNR Order
- EMS personnel must match the name on the DNR order form to the identity of the patient.
- EMS personnel must agree that the out-of-hospital TDH DNR order form appears to be valid.
- If the patient is found in or develops cardiac and/or respiratory arrest,
a. EMS personnel will honor the DNR order by withholding placement of the AED, manual defibrillator, CPR, transcutaneous pacing, advanced airway, and artificial ventilation.
b. If assessment or treatment begins and someone presents a valid DNR order form for the patient, EMS personnel will stop the assessment and/or treatment immediately - even if a positive
response has occurred.
- If the patient has a DNR order that appears valid, and the patient is not in cardiac or respiratory arrest,
a. EMS personnel will provide care, such as opening the patient’s airway, providing oxygen, IV fluids or medications (other than resuscitation medications), or any other treatment directed toward
making the patient comfortable.
b. The DNR Order form must accompany the patient during transport.
Following the field declaration of death, EMS personnel should contact BioTel to document statistical information
required by Texas Department of State Health Services. When the response team encounters a DNR order form,
a bracelet, or a necklace, the medic should document the following items within the patient care record.
- An assessment of the patient’s condition
- The type of DNR device (DNR paper form, bracelet, or necklace) used to confirm the DNR status
- Any problems encountered during implementation of the DNR order
- The name of the patient’s attending physician
- The full name, address, telephone number, and relationship to the patient of any witness used to identify patient