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Massachusetts Do Not Resuscitate (DNR) Order Form

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Massachusetts Do Not Resuscitate (DNR) Order Form

Updated May 31, 2022

A Massachusetts do not resuscitate (DNR or DNAR) order form is a document that patients may obtain from their doctors if, for personal or health-related reasons, they do not wish to be resuscitated. This document, which may be signed on behalf of the patient by an authorized representative, parent, or legal guardian, indicates that cardiopulmonary resuscitation (CPR) will not be used in the treatment of said patient unless the DNR order is revoked by the patient or their representative. Once issued, the order will be put into the patient’s medical records and will often be printed on bright-colored paper in order to alert medical staff of its existence.

LawsLegal Guide to Do Not Resuscitate (DNR) Orders

Required to Sign – Patient (or legal guardian) and physician.

How to Write

Step 1 – Download the Massachusetts Comfort Care/DNR Order Verification form.

Step 2 – Enter the patient’s full name, date of birth, and gender into the indicated fields.

Step 3 – Next, supply their complete address and full name of their guardian or health care agent (if applicable).

Step 4 – Below that, either the patient or someone authorized to represent them must enter their name, check the appropriate box to indicate who they are, provide their signature, and supply the date.

Step 5 – At the bottom of the page, you will need to enter the date that the DNR Order was issued on and whether it has an expiration date. Below that, provide your signature, printed name, start and expiry date of the DNR Order, your address, and your telephone number. Once complete, this form must be included in the patient’s medical record.