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Out-of-Hospital DNR Orders

Planning for Loss of Health

This article discusses Out-of-Hospital Do Not Resuscitate Orders.

Here, learn about the Out-of-Hospital DNR, a form that tells emergency medical professionals not to perform certain life-saving procedures when you are unconscious and not in the hospital. It lets you have some control over how much medical treatment you receive.

What is an Out-of-Hospital DNR order?

An Out-of-Hospital DNR is a legal form that tells emergency medical professionals not to start or continue certain life-saving procedures. DNR is short for “do not resuscitate.” Resuscitation is when someone who has stopped breathing and whose heart has stopped beating is restored to consciousness

If you are not in the hospital and have a medical emergency that makes you unconscious, emergency medical professionals (EMS) may be called to help. If you have a valid Out-of-Hospital DNR, EMS will not use any of the five procedures listed in the Out-of-Hospital DNR form to revive you.

You can fill out a Texas Out-of-Hospital DNR form if you want to. To be valid in Texas, you must use the Texas form.

Facts About the Texas Out-of-Hospital DNR

The Texas Out-of-Hospital DNR:

  • Is free
  • Does not affect your will, estate, or finances
  • Does not affect your health or life insurance premiums
  • Is signed by your doctor
  • Applies only to certain procedures given by EMS, hospital emergency room personnel, nursing home staff, or other health care professionals
  • Allows you to have some control over how much medical treatment you receive and for how long
  • Does not prevent treatment and medicine to reduce pain
  • Does not allow mercy killing or assisted suicide
  • Does not require a lawyer or notary to complete
  • Can be canceled (revoked) at any time, regardless of your mental state.

Do I need an Out-of-Hospital DNR?

You have the right to decide if you should get medical treatment. If you stop breathing or your heart stops beating, you may not want to be revived with electric shock or a breathing tube. You can use an Out-of-Hospital DNR order to tell emergency medical providers that you do not want them to take extraordinary measures to keep you alive. An Out-of-Hospital DNR order gives you some control over your emergency treatment if you are unconscious. If you are in critical condition, an Out-of-Hospital DNR allows you to die a natural death. 

What treatments are covered by an Out-of-Hospital DNR?

With a Texas Out-of-Hospital DNR order, emergency medical professionals cannot start or continue:

  • cardiopulmonary resuscitation (CPR: chest compressions and airway) 
  • advanced airway management (clearing the airway, usually with a breathing tube)  
  • artificial ventilation (machine or procedure to restore breathing)  
  • defibrillation (electrical shock to the heart with a defibrillator machine)  
  • transcutaneous cardiac pacing (electrical impulses to the heart using electrodes attached to the skin)

EMS is allowed to provide treatment and pain medicine to make you more comfortable. 

What is the difference between an In-Hospital DNR and an Out-of-Hospital DNR?

Both types of DNR orders require your consent and are made part of your medical record. In-Hospital DNR orders are sometimes called “no code” orders. An In-Hospital DNR order tells hospital staff not to resuscitate you. An Out-of-Hospital DNR order instructs emergency medical personnel, hospital emergency room staff, nursing home staff, and other health care professionals not to resuscitate you.

What is the difference between a DNR, Directive to Physicians, and Medical Power of Attorney?

An Out-of-Hospital DNR is signed by your doctor and tells emergency medical personnel not to use certain procedures to resuscitate or revive you.

A Directive to Physicians tells your doctor to withhold or withdraw certain life-saving treatments if your doctor certifies that your condition is terminal or irreversible.

A Medical Power of Attorney tells another person you chose to make health care decisions for you. Your condition does not have to be terminal or irreversible, but that person can act on your behalf only when you are incompetent or cannot make your wishes known to your doctor.

Do I need a DNR if I already have a Directive to Physicians?

If you already have a valid Directive to Physicians, your doctor can rely on it to issue any DNR on your behalf.  However, if you want a DNR order to provide instructions to EMS, you should execute your own DNR order.

What is required for an Out-of-Hospital DNR?

The Texas Out-of-Hospital DNR form requires your signature, the signatures of your doctor, and the signatures of two competent adult witnesses or a notary instead of the witnesses.

If you use two witnesses, rather than a notary, one of the two witnesses cannot be:

  • Your relative (by blood or marriage)
  • Someone entitled to any part of your estate
  • Someone with a claim against your estate
  • Anyone you’ve named to make a treatment decision for you
  • Your doctor or your doctor’s employee
  • An employee who cares for you at the health care facility where you are a patient, or
  • An owner or admissions officer of the health care facility where you are a patient.

Your Out-of-Hospital DNR order must stay with you if you are taken to a hospital. 

When does an Out-of-Hospital DNR take effect?

The Out-of-Hospital DNR form takes effect as soon as it has been signed by all the parties, including the attending physician. Once signed, it applies wherever you are – at home, in a nursing home, in the emergency room, at a clinic, in the grocery store. Texas law says that “Out-of-Hospital” locations also include:

  • long-term care facilities
  • in-patient hospice facilities
  • private homes
  • hospital outpatient or emergency departments
  • doctors’ offices
  • vehicles during transport

Can anyone else issue an Out-of-Hospital DNR for me?

Yes. If you are competent you can issue your own Out-of-Hospital DNR. Your doctor will note in your medical record that you have one. If you are unable to give consent, one can be issued for you by:

  • Your legal guardian
  • Your agent under a Medical Power of Attorney
  • Your doctor, if you have a Directive to Physicians
  • The following relatives, in order of priority:
    • your spouse
    • your adult children
    • your parents, or
    • your nearest living relative

If none of the above is available, your doctor can issue an Out-of-Hospital DNR with the consent of another doctor who is not involved in your treatment and/or is a member of a hospital’s medical ethics committee.

How do I revoke (cancel) an Out-of-Hospital DNR?

You can revoke your Out-of-Hospital DNR at any time by destroying it. You can also tell EMS at the scene that you’ve changed your mind or tell your doctor that you want to revoke it. It is not in effect if you are pregnant. If you revoke your Out-of-Hospital DNR, inform your doctor and ask that it be noted in your medical record.

Where should I keep my Out-of-Hospital DNR after it is signed?

Keep your signed, original form where emergency medical professionals can find it easily.

An identification bracelet or necklace can prove that you have an Out-of-Hospital DNR. But in Texas, it must be:

  • A plastic bracelet with the word “Texas” and the words “Do Not Resuscitate” (or the shape of the State of Texas and the word “STOP” over the shape)
  • A metal bracelet or necklace with the words, “Texas Do Not Resuscitat–OOH.”

Plastic bracelets can be ordered from:

Texas Medical Association
401 W. 15th Street
Austin, TX 78701
Telephone order line: 512-370-1306

You can order approved metal identification jewelry from:

MedicAlert Foundation, Inc.
2323 Colorado Ave.
Turlock, CA 95382

American Medical Identifications, Inc.
949 Wakefield, Suite 100
Houston, TX 77018

For More Information

Contact the Office of the Attorney General of Texas. Ask for the Advance Care Planning guide.

Senior Texans
P.O. Box 12548,
Austin, TX 78711-2548
Telephone: 800-252-8011

Contact the American Bar Association. Ask for the Tool Kit for Health Care Advance Planning.

ABA Commission on Law and Aging
740 15th St. NW,
Washington, DC 20005
Telephone: 202-662-8690

Legal Hotline for Texans: 800-622-2520. Call our lawyer-staffed legal hotline. Advice is free for Texans 60 and over or for anyone eligible for Medicare.

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