eForms Logo

Texas Do Not Resuscitate (DNR) Order Form

Create a high-quality document now!

Texas Do Not Resuscitate (DNR) Order Form

Updated July 19, 2023

Texas do not resuscitate (DNR) order form can be used by a patient to willfully decline life-saving treatments when their heart or lungs cease to function. The order informs emergency medical personnel that the individual does not wish to receive cardiopulmonary resuscitation (CPR), defibrillation, artificial ventilation, transcutaneous cardiac pacing, and advanced airway management. Medical staff attending to a patient during an emergency must view the DNR order or else resuscitative treatments will be applied.

Two (2) competent adults must witness the signatures provided by the patient or their authorized representative. If the patient or representative is incapable of signing, the witnesses must witness the nonwritten communication made to the attending physician. Optionally, a notary public may be present when the document is executed.

Laws –  § 157.25 and Chapter 166

Required to Sign – Physician, patient (or representative + relative), and 2 witnesses (or 2nd physician).

How to Write

Step 1 – Start by downloading the Texas DNR order form in PDF.

Step 2 – Enter the patient’s full legal name followed by their date of birth and gender.

Step 3 – Section A should only be completed by the patient if they are competent and at least eighteen (18) years of age. If the patient is incompetent and unable to sign, proceed to step (4).

In section A, the patient must provide their signature and date the document. They must then print their name in the remaining space.

Step 4 – Sections B through D should only be completed if the patient is incompetent or incapable of communicating properly.

In section B, the patient’s authorized representative must specify their status (i.e., legal guardian, agent, proxy). Next, they must provide their signature followed by the date of execution and their printed name.

In section C, a qualified relative of the patient must specify their relationship to the patient. Next, they must provide their signature, enter the date the form was signed, and print their name.

In section D, the patient’s physician must select one (1) of the checkboxes to specify whether they saw evidence of the patient’s previously issued directive, or if they observed the patient’s issuance before two (2) witnesses in a nonwritten manner. The physician must then provide their signature, date the document, print their name, and enter their license number.

Step 5 – If the DNR order was requested on behalf of a minor patient, the minor’s parent/guardian/managing conservator must complete section E.

The individual must specify their status by selecting one (1) of the available checkboxes. Below that, the person must sign the form, enter the date, and print their name.

Step 6 – Do not complete this section if the patient is incompetent or unable to communicate properly and does not have an agent, proxy, guardian, or qualified relative available to act on their behalf.

Two (2) witnesses must provide their signatures, date the document, and print their names. If a notary public witnessed the patient or representative sign the document, they must fill out the remaining portion of this section by supplying the following:

  • County of operation
  • Date of signing
  • Signature
  • Printed name
  • Seal

Step 7 – Below “PHYSICIAN’S STATEMENT,” the attending physician must supply their signature before entering the date, printed name, and license number.

Step 8 – Section F should only be completed if the patient is incompetent or otherwise incapable of communicating properly.

The attending physician must provide their signature, date the document, print their name, and enter their license number. In the remaining spaces, a second physician must concur to the issuance of the form by supplying the same information (the second physician must not be involved in the treatment of the patient unless they are a representative of the medical or ethics committee of the medical facility where the person was treated).

Step 9 – All individuals who have signed the DNR order must provide their signatures once again. The remaining spaces of the document have been designated for this purpose.