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Nevada Do Not Resuscitate (DNR) Order Form

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Nevada Do Not Resuscitate (DNR) Order Form

Updated May 31, 2022

A Nevada do not resuscitate (DNR) order form is a document that instructs medical personnel not to administer cardiopulmonary resuscitation (CPR) to the patient if their heartbeat and/or breathing stops. To issue a DNR order, the subject, or their authorized health agent, must obtain, fill out, and sign a DNR Application Form from their physician, who must also sign. Once completed, the completed application must be sent to the address below, along with a check or money order payable to the “Division of Public and Behavioral Health.”

Emergency Medical Systems
4150 Technology Way, Suite 101
Carson City, NV 89706

In order to apply for a DNR order, the subject must be in the critical stages of an illness. Therefore, affected individuals may be better served by the Nevada POLST Form, which details instructions not only regarding CPR but a plethora of other end-of-life treatments. The POLST form is also issued by the patient’s attending physician upon the request/consultation of the patient or their authorized health agent.

Laws§ 449A-433§ 450B.510, § 450B.520

Required to Sign – Patient (or representative), the attending physician, and the preparer of the document.

How to Write

Step 1 – Download in Adobe PDF.

Step 2 – First, enter the patient’s full name, date of birth, last four (4) digits of their Social Security Number, and select their gender by marking “M” or “F” for “male” or “female.”

Step 3 – Check the appropriate box to indicate whether or not CPR should be attempted if the patient experiences a cardiac and/or pulmonary arrest.

Step 4 – In Section B, you need to indicate which types of comfort measures, medical interventions, and administration of fluids/nutrition should be permitted in treating the patient.

Step 5 – Next you must supply the date, along with the physician’s signature, name, address, phone number, and license number.

Step 6 – Enter the patient’s name and their date of birth at the top of the next page.

Step 7 – If the patient is donating their organs, mark the checkbox and write any instructions if necessary.

Step 8 – In Section E, you will have to indicate if the patient has an advanced directive. If they do, select “Yes” or “No” to indicate whether it is registered with the Secretary of State and what its registration number is (if applicable). Furthermore, if the patient has any appointed agents or a court-appointed guardian, enter their names and telephone numbers in the appropriate fields.

Step 9 – Supply the patient or representative’s signature and enter the date. Next, check the appropriate box(es) to indicate the individual who gave consent regarding CPR and other interventions was discussed with and (if applicable) provide the name of a witness and the date that the consent to place. As the person preparing the form, provide your name, the date, and your signature in the indicated fields. Finally, the physician must enter their initials in Section G in order to verify that they have informed the patient that the POLST Form should be filed in a Living Will Lockbox.