California Do Not Resuscitate (DNR) Order Form

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Updated May 31, 2022

The California do not resuscitate order form (DNR) is a document that, when signed by a patient and their physician, will prevent EMTs, paramedics, and other emergency personnel from performing any medical procedures on an individual if their heart stops beating or they stop breathing. Under any other circumstance, medical emergency personnel are trained to save lives – this most often includes resuscitating a patient who is dying. A person who is very sick, weak or otherwise does not wish to receive life-prolonging treatment, can avoid CPR, ACLS, and other types of resuscitation by requesting a DNR form. The individual should wear an indicator, or keep documentation on their person, at all times. Medical personnel will see this indicator and will refrain from performing any resuscitation procedures.

LawsPROB § 4780 – 4788

Required to Sign – Patient and physician.

How to Write

Step 1 – Download the form in Adobe PDF.

Step 2 – Enter the patient’s name in the first available field.

Step 3 – If the patient is competent (i.e., able to make informed decisions on their own), they must sign and date the form on the available lines. Otherwise, the patient’s legal health care proxy must sign and date the form. In the latter circumstance, the proxy must include their relationship to the patient.

Step 4 – A physician must sign the form to indicate their approval of this order. The physician must also include the date, their printed name, and their phone number.