To get an Out-of-Hospital DNR in Texas, you complete the form prescribed by the Texas Department of State Health Services, have the patient (or an authorized representative) sign it in front of two qualified witnesses or a notary public, and get an attending physician licensed in Texas to sign the physician’s section.1Department of State Health Services. Out-of-Hospital DNR Order Form After that, the practical work begins: keep the form where paramedics will see it, or wear an approved DNR bracelet or necklace so the order travels with the patient. Miss a step and responders will default to full resuscitation, no matter what family members tell them at the scene.
Confirm Who Is Allowed to Sign
A competent adult can execute an OOH-DNR for themselves. “Competent” under Texas law means the person can understand and appreciate the nature and consequences of the treatment decision, including its benefits, harms, and alternatives.2State of Texas. Texas Health and Safety Code 166.002 – Definitions A verbal request is not enough. The directive has to be in writing on the prescribed form.
If the patient lacks decision-making capacity, a legal guardian or an agent named under a Medical Power of Attorney may sign in their place. The Medical Power of Attorney must specifically grant authority over life-sustaining treatment. If the patient previously signed a Directive to Physicians (Texas’s living will) under Subchapter B of Chapter 166, the attending physician may rely on that directive as the patient’s instructions and sign the OOH-DNR in the patient’s place.3Texas Public Law. Texas Health and Safety Code 166.082 – Out-of-Hospital DNR Order
For a minor, a parent, legal guardian, or managing conservator may execute an OOH-DNR, but only after a physician has diagnosed the minor with a terminal or irreversible condition. If the minor is in state custody, the Texas Department of Family and Protective Services and possibly a court may have to be involved first. And a minor old enough to communicate who tells responders they want resuscitation overrides the order.4State of Texas. Texas Health and Safety Code 166.086 – Desire of Person Supersedes Out-of-Hospital DNR Order
Use the DSHS Form and Get the Right Signatures
Texas requires a standardized form prescribed by DSHS.1Department of State Health Services. Out-of-Hospital DNR Order Form Deviations from the prescribed format put the order at risk of being unrecognized by first responders. Three sets of signatures are needed for a standard execution.
The Declarant
The patient signs the form. If a legal representative is acting for an incapacitated patient, that representative signs instead.
Two Qualified Witnesses (or a Notary)
Both witnesses must be competent adults present when the declarant signs. At least one witness has to meet the stricter qualifications under Section 166.003 of the Health and Safety Code, which disqualifies people related to the patient by blood or marriage, anyone entitled to a portion of the patient’s estate, the patient’s attending health care provider, employees of a facility where the patient resides, and anyone with a financial interest in the patient’s death.
If finding two qualified witnesses is difficult, Texas offers an alternative: the declarant may sign the form and have the signature acknowledged before a notary public.3Texas Public Law. Texas Health and Safety Code 166.082 – Out-of-Hospital DNR Order The notary path is useful for patients who live alone or in rural areas.
The Attending Physician
Only a doctor licensed by the Texas Medical Board or an active-duty military physician may sign the physician’s section. Nurse practitioners and physician assistants cannot sign. The physician also has to document the order and the reasons for it in the patient’s medical record.5Department of State Health Services. Honoring an Out-of-Hospital DNR Order The physician’s signature is required whether you used two witnesses or a notary.
Get an Approved DNR Identification Device
A signed form sitting on a kitchen counter does not help if the patient collapses at the grocery store. Texas law lets a person with a valid OOH-DNR wear an approved identification device as a substitute for the paper order. Under Texas Administrative Code Section 157.25, two device types are recognized:
- A plastic bracelet displaying the word “Texas” (or a representation of the geographic shape of Texas with the word “STOP” superimposed) and the words “Do Not Resuscitate.”6Cornell Law School. 25 Texas Admin Code 157.25 – Out-of-Hospital Do Not Resuscitate (OOH-DNR) Order
- A metal bracelet or necklace inscribed with the words “Texas Do Not Resuscitate – OOH.”6Cornell Law School. 25 Texas Admin Code 157.25 – Out-of-Hospital Do Not Resuscitate (OOH-DNR) Order
The device has to be intact and unaltered to be honored by EMS personnel. Patients buy them at their own expense, and typical costs for approved bracelets and necklaces run roughly $25 to $40. Either a valid device or a copy of the completed form is sufficient evidence that the order exists.7Texas DSHS. Out of Hospital Do Not Resuscitate Program
Make Sure Responders Can Find It
Paramedics have two or three minutes before they start CPR. The order needs to be findable in that window.
Keep the original or a copy of the completed form in a prominent spot at home. A refrigerator door is the most commonly recommended location because EMS personnel in many jurisdictions are trained to check there. Near the patient’s bed is another option, especially in home hospice situations. Anyone involved in daily care, from family to home health aides, should know where the form is and what it means.
When a patient moves between care settings, such as from a nursing home to an assisted living facility, the OOH-DNR should travel with them and be added to their medical records at the new location. HIPAA permits health care providers to share DNR status with responding paramedics as part of treating the patient.8U.S. Department of Health and Human Services, Office for Civil Rights. HIPAA Privacy in Emergency Situations
How to Revoke the Order
An OOH-DNR can be revoked at any time, and the bar is deliberately low. The statute says a declarant may revoke “without regard to the declarant’s mental state or competency.”9State of Texas. Texas Health and Safety Code 166.092 – Revocation of Out-of-Hospital DNR Order Revocation happens in any of these ways:
- Physically destroying the form by tearing, burning, or similar means.
- Telling a health care professional the order is revoked, or putting the revocation in writing.
- Removing, or trying to remove, a DNR bracelet or necklace. Responders should treat visible attempts to pull off the device as revocation even if the patient cannot speak.
A representative who executed the order on behalf of an incapacitated patient can also revoke it. If there is any real doubt about whether the patient wants the order revoked, the safe default is resuscitation. Tell every caregiver and update medical records immediately after a revocation, or the order may still be followed by mistake.
What the Order Does and Does Not Cover
An OOH-DNR directs responding health care professionals to withhold CPR and other life-sustaining treatment specified by DSHS.10State of Texas. Texas Health and Safety Code 166.081 In practice that means chest compressions, defibrillation, advanced airway management, and artificial ventilation. Texas does not allow a partial OOH-DNR: either all resuscitative measures are withheld, or none are.
The order applies only outside hospitals. Once the patient is admitted, in-hospital code status and separate physician orders take over. The OOH-DNR does not affect pain management, comfort oxygen, or treatment of injuries unrelated to a cardiac or respiratory arrest. It also does not cover feeding tubes, antibiotics, or hospitalization preferences short of arrest; a Directive to Physicians and a Medical Power of Attorney handle those broader questions.
A Texas OOH-DNR may not be recognized in another state. No federal law requires states to honor each other’s out-of-hospital DNR orders, and formats vary. Patients who split time between states should obtain an equivalent order in each state where they spend significant time.
No One Can Require You to Sign
Texas law prohibits physicians, health facilities, insurers, and health care service plans from requiring a person to execute an advance directive, including an OOH-DNR, as a condition of receiving care or coverage. Signing is entirely voluntary, and access to treatment or insurance cannot be conditioned on having or not having a DNR order in place.