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Texas Do Not Resuscitate Form

This is the Texas out-of-hospital do-not-resuscitate (OOH-DNR) order provided by Texas Department of State Health Services.

Texas Do Not Resuscitate Form
Texas Do Not Resuscitate Form
OUT-OF-HOSPITAL DO-NOT-RESUSCITATE (OOH-DNR) ORDER
TEXAS DEPARTMENT OF STATE HEALTH SERVICES
This document becomes effective immediately on the date of execution for health care professionals acting in out-of-hospital settings. It remains in effect until
the person is pronounced dead by authorized medical or legal authority or the document is revoked. Comfort care will be given as needed.
Person's full legal name
Date of birth
Male
Female
A. Declaration of the adult person: I am competent and at least 18 years of age. I direct that none of the following resuscitation measures be initiated or continued for me:
cardiopulmonary resuscitation (CPR), transcutaneous cardiac pacing, defibrillation, advanced airway management, artificial ventilation.
Date
B. Declaration by legal guardian, agent or proxy on behalf of the adult person who is incompetent or otherwise incapable of communication:
I am the:
legal guardian;
agent in a Medical Power of Attorney; OR
proxy in a directive to physicians of the above-noted person who is incompetent or otherwise
mentally or physically incapable of communication.
Based upon the known desires of the person, or a determination of the best interest of the person, I direct that none of the following resuscitation measures be initiated or continued for the
person: cardiopulmonary resuscitation (CPR), transcutaneous cardiac pacing, defibrillation, advanced airway management, artificial ventilation.
Date
Printed name
E. Declaration on behalf of the minor person: I am the minor's:
parent;
legal guardian; OR managing conservator.
Printed name
Date
TWO WITNESSES: (See qualifications on backside.) We have witnessed the above-noted competent adult person or authorized declarant making his/her signature above and, if applicable, the
above-noted adult person making an OOH-DNR by nonwritten communication to the attending physician.
Printed name
Printed name
PHYSICIAN'S STATEMENT: I am the attending physician of the above-noted person and have noted the existence of this order in the person's medical records. I direct health care professionals
acting in out-of-hospital settings, including a hospital emergency department, not to initiate or continue for the person: cardiopulmonary resuscitation (CPR), transcutaneous cardiac
pacing, defibrillation, advanced airway management, artificial ventilation.
Printed name
Date
License #
Date
Date
F. Directive by two physicians on behalf of the adult, who is incompetent or unable to communicate and without guardian, agent, proxy or relative: The person's specific wishes are unknown, but resuscitation measures
are, in reasonable medical judgment, considered ineffective or are otherwise not in the best interests of the person. I direct health care professionals acting in out-of-hospital settings, including a hospital emergency
department, not to initiate or continue for the person: cardiopulmonary resuscitation (CPR), transcutaneous cardiac pacing, defibrillation, advanced airway management, artificial ventilation.
Printed
name
Date
Date
Printed
name
All persons who have signed above must sign below, acknowledging that this document has been properly completed.
Second physician's signature
This document or a copy thereof must accompany the person during his/her medical transport.
Signature of second physician
Physician's electronic or digital signature must meet criteria listed in Health and Safety Code §166.082(c).
Person's signature
Witness 1 signature
Witness 2 signature
Attending physician's signature
Person's signature
Attending physician's
signature
Lic#
Lic#
Printed name
C. Declaration by a qualified relative of the adult person who is incompetent or otherwise incapable of communication: I am the above-noted person's:
spouse, adult child,
parent, OR
nearest living relative, and I am qualified to make this treatment decision under Health and Safety Code §166.088.
To my knowledge the adult person is incompetent or otherwise mentally or physically incapable of communication and is without a legal guardian, agent or proxy. Based upon the known desires of
the person or a determination of the best interests of the person, I direct that none of the following resuscitation measures be initiated or continued for the person: cardiopulmonary
resuscitation (CPR), transcutaneous cardiac pacing, defibrillation, advanced airway management, artificial ventilation.
Printed name
Date
Notary's
signature
Witness 1 signature
Witness 2 signature
Guardian/Agent/Proxy/Relative signature
Physician's signature
Notary in the State of Texas and County of___________________. The above noted person personally appeared before me and signed the above noted declaration on this date:______________.
Signature & seal:
_______________________________________________Notary's printed name:_______________________________________________ Notary Seal
[ Note: Notary cannot acknowledge the witnessing of the person making an OOH-DNR order in a nonwritten manner ]
A physician has diagnosed the minor as suffering from a terminal or irreversible condition. I direct that none of the following resuscitation measures be initiated or continued for the person:
cardiopulmonary resuscitation (CPR), transcutaneous cardiac pacing, defibrillation, advanced airway management, artificial ventilation.
D. Declaration by physician based on directive to physicians by a person now incompetent or nonwritten communication to the physician by a competent person: I am the above-noted
person's attending physician and have:
seen evidence of his/her previously issued directive to physicians by the adult, now incompetent; OR
observed his/her issuance before two witnesses of an OOH-DNR in a nonwritten manner.
I direct that none of the following resuscitation measures be initiated or continued for the person: cardiopulmonary resuscitation (CPR), transcutaneous cardiac pacing, defibrillation,
advanced airway management, artificial ventilation.
Lic#
Printed
name
Date
Attending physician's
signature
Signature
Signature
Signature
Figure: 25 TAC §157.25 (h)(2)
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