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Kentucky Do Not Resuscitate (DNR) Order Form

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The Kentucky do not resuscitate (DNR) order form is an agreement between a patient and all medical personnel stating that the patient does not wish to be resuscitated in the event of cardiac or respiratory arrest. A person, typically one suffering from a terminal illness or other medical condition (a condition which, when combined with CPR, would worsen), who completes a DNR form prefers to die naturally than to be brought back to life. However, emergency personnel may provide other medical care, such as treatments and medications to make the patient more comfortable. In Kentucky, it is the full responsibility of the patient, or their authorized representative, to request a DNR order; a physician is not required to provide confirmation of their patient’s health status.

Lawsยง 311.623

Required to Sign – Patient and a notary public OR two (2) witness not related to the patient.

How to Write

Step 1 – Download the Do Not Resuscitate Order in Adobe PDF.

Step 2 – Enter the person’s (patient’s) full name and their surrogate’s name (if applicable).

Step 3 – The person executing the order (patient or their representative) must include their signature and the date on the appropriate lines.

Step 4 – A notary public OR two (2) witnesses must observe the document being signed by the executor. After the patient/representative has signed, the notary or witnesses can sign the DNR form.

Step 5 – The section at the very bottom of the page should be completed and inserted into the patient’s DNR bracelet. This includes the patient’s (or representative’s) name and signature.


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