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This is the Texas out-of-hospital do-not-resuscitate (OOH-DNR) order provided by Texas Department of State Health Services.
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
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:
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.
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).
Witness 1 signature
Witness 2 signature
Attending physician's signature
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,
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
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