How to Get and Fill Out the Kentucky EMS DNR Form

The Kentucky EMS DNR form is a one-page medical order, approved by the Kentucky Board of Medical Licensure, that instructs paramedics and EMTs not to perform CPR or other resuscitation on a patient who has no pulse and is not breathing.¹ To put it in force, you download the official form, have the qualifying patient or an authorized surrogate sign it, and keep the original (or the detachable bracelet insert) where responders can see it the moment they arrive. It applies only outside the acute care hospital setting: at home, in a long-term care facility, or during transport.

Who Can Sign It

Kentucky ties the EMS DNR to a diagnosis of a terminal condition. Under KRS 311.621, that means an injury, disease, or illness that two physicians — the attending physician and one additional physician — determine to a reasonable degree of medical probability is incurable, irreversible, and will result in death within a relatively short time, where life-prolonging treatment would only artificially extend the dying process.² A single doctor’s opinion is not enough.

A patient with capacity to make healthcare decisions signs the form personally. If the patient cannot act for themselves, a court-appointed guardian or designated health care surrogate can sign on their behalf. Keep documentation of the surrogate’s or guardian’s legal authority with the form, because responders may need to confirm who authorized it.

Where to Download the Form

The official PDF is titled “Kentucky Emergency Medical Services Do Not Resuscitate (DNR) Order” and is available from the Kentucky Board of Emergency Medical Services (KBEMS) website. The current version was approved by the Kentucky Board of Medical Licensure at its March 2024 meeting.¹ Your attending physician’s office may also have copies.

Only the state-approved template works. Kentucky law recognizes a prehospital refusal of resuscitation only when it appears on the standard form or identification approved by the Kentucky Board of Medical Licensure, or on a Medical Orders for Scope of Treatment (MOST) form approved under KRS 311.6225.³ A handwritten note, a letter from a doctor, or a generic living will does not stop resuscitation in the field.

How to Fill It Out

The main section of the form asks for very little:

The patient’s full legal name, printed as it appears on official identification.
The surrogate’s full legal name, if a surrogate or guardian is acting on the patient’s behalf. Leave this blank if the patient signs personally.
The date of signing.
The signature of the patient or the authorized surrogate.

At the bottom of the page there is a detachable bracelet insert. Cut it out, fold it, and slide it into a standard hospital-type identification wristband. The insert requires the patient’s printed name and either the patient’s or the surrogate’s signature.¹

If the patient will be transferred between facilities, the form includes separate signature and date lines for the person sending the patient out and the person receiving the patient back. Completing those lines keeps the chain of documentation unbroken so the order follows the patient.

One hard rule: any attempt to alter or change the content, names, or signatures on a completed form makes it invalid.¹ If you need to correct a field, start over with a fresh form. Do not cross out, write over, or initial changes.

Where to Keep It So EMS Will Honor It

The original completed form or the bracelet must be readily available and shown to EMS personnel the moment they arrive. If neither is produced, responders follow their normal protocols, which include CPR and other resuscitation procedures.¹ Resuscitation can begin and continue until the form or bracelet is located and the patient’s identity is confirmed.

Common storage spots are the refrigerator door or the wall beside the patient’s bed, since those are the first places EMS crews look for medical directives. A clear plastic sleeve protects the paper without hiding it. In a long-term care facility, the staff should know exactly where the document is kept and be able to hand it to a responder within seconds.

The bracelet is the alternative for patients who are mobile or often away from home. Responders treat the bracelet as equivalent to the paper form for the purpose of honoring the order.

What Makes the Form Fail

EMS personnel in Kentucky have no discretion on this point. Without a valid, original form or bracelet physically present and shown to them, they are required to initiate full resuscitation, including chest compressions, defibrillation, and intubation.⁴ A family member’s verbal assurance that a DNR exists somewhere does not substitute for the document. A photocopy tucked in a drawer may not satisfy the requirement for the original.

An altered form is explicitly invalid under its own terms. If responders see signs of tampering, they will treat the form as if it does not exist. The same outcome applies if the form is unsigned or missing the date. Any blank required field is a reason for crews to default to resuscitation.

If You Also Want to Limit Other Treatments: The MOST Form

Kentucky recognizes a second document for prehospital care, the Medical Orders for Scope of Treatment (MOST) form. The EMS DNR does one thing: it stops resuscitation when the patient has no pulse and is not breathing. The MOST form includes a resuscitation section that functions like a DNR, plus a separate section covering medical interventions for situations where the patient still has a pulse or is still breathing, such as hospital transfer, IV fluids, and the overall intensity of treatment.⁵

The MOST form is intended for patients with an advanced chronic progressive illness or a life expectancy of less than one year. If the only question is CPR, the standalone EMS DNR is the simpler route. If you also want to set limits on ventilators, feeding tubes, or levels of hospital care, MOST handles all of that in one document. Without either form, EMS crews provide full advanced cardiac life support by default.⁵

How to Revoke It

A patient who regains or retains decision-making capacity can revoke the order. The simplest method is to physically destroy the form and the bracelet insert. Because the order depends on the original document being presented to EMS, eliminating that document ends the order.

Tell everyone who matters: the physician, home health aides, nursing facility staff, and the family members most likely to be present during an emergency. A revoked order that still sits on the refrigerator because no one took it down can produce exactly the outcome the patient no longer wants.

Using the Form Outside Kentucky

The Kentucky EMS DNR form is specific to Kentucky. Other states use their own DNR and POLST forms with their own requirements, and there is no federal rule forcing states to honor each other’s prehospital DNR orders. A patient traveling or relocating should obtain the destination state’s approved form and have it completed with a local physician.

The reverse applies too. An out-of-state DNR brought into Kentucky may not be recognized by Kentucky EMS crews, who are trained to look for the form approved by the Kentucky Board of Medical Licensure.³ Anyone moving to Kentucky with a DNR from another state should work with a Kentucky-licensed physician to complete the state-approved form as soon as possible.

1
Kentucky Board of Emergency Medical Services. Kentucky EMS Do Not Resuscitate Order
2
Kentucky Legislative Research Commission. Kentucky Revised Statutes 311.621 – Definitions for KRS 311.621 to 311.643
3
Kentucky Legislative Research Commission. Kentucky Revised Statutes 311.623 – Living Will Directive or Medical Order for Scope of Treatment
4
Kentucky Board of Emergency Medical Services. Kentucky EMS State Protocols
5
Kentucky Board of Medical Licensure. Board Opinion MOST