Indiana Out of Hospital DNR: Form, Bracelet, and EMS Response

An Indiana out-of-hospital DNR lets a qualifying patient tell emergency responders not to perform CPR if the patient’s heart or breathing stops outside a hospital. It takes two pieces of paper working together: a written declaration signed by the patient (or an authorized representative) in front of two witnesses, and an accompanying order signed by the patient’s attending physician, advanced practice registered nurse, or physician assistant. The rules are set out in Indiana Code 16-36-5, and the state publishes a single official form that combines both parts.

Who Can Get One

The patient has to be certified as a “qualified person” before the declaration can be executed. The attending physician, APRN, or physician assistant makes that call using reasonable medical standards, and must find at least one of the following: the patient has a terminal condition, or the patient has a medical condition where CPR would either be unsuccessful or would only produce repeated cardiac or pulmonary failure and death within a short period.¹

The person signing has to be at least eighteen and of sound mind. There is no exception for emancipated minors. If an adult patient is incapacitated or incompetent, a legally authorized representative can sign for them, and if no representative is available, a proxy designated under Indiana’s healthcare consent law may sign.²

Making the Declaration Valid

Indiana law is specific about the formalities. The declaration must be voluntary, in writing, dated, and signed by the declarant (or by another person at the declarant’s direction and in the declarant’s presence). It must be signed in front of at least two competent witnesses.² A notary is not a substitute for the two witnesses, and one witness is not enough.

Counterpart signing is allowed. The declaration and witness signatures can appear on separate paper counterparts as long as the document says it is being signed in counterparts and someone assembles all pages into a single composite document within ten business days. The statute also permits telephonic interaction for signing, provided the witness personally knows who the declarant is.²

The Physician or APRN Order

After the patient signs, the attending physician, APRN, or physician assistant reviews the declaration and issues the DNR order.³ Only the declarant’s own attending provider can issue it. Another doctor who happens to be around cannot step in. The order confirms that the provider has reviewed the declaration, that the declarant is of sound mind, and that signing was voluntary, and it carries the provider’s license number.⁴

The Official Form

Indiana law requires the declaration and order to follow the format set out in the statute itself.⁵ The Indiana Department of Health publishes the official version as State Form 49559. It contains the declarant’s name, the date, the declarant’s or representative’s signature, and the attending provider’s signature and license number, along with a built-in revocation section so the patient can revoke later without a separate document.⁴ The attending provider keeps copies of the completed declaration and order.⁶

The DNR Bracelet or Necklace

Indiana authorizes a physical identification device (a necklace or bracelet) that flags a valid DNR to responders. The Indiana Emergency Medical Services Commission develops the device, which is inscribed with the declarant’s name, date of birth, and the words “Do Not Resuscitate.”⁷

Two limits are worth knowing. The device can only be produced after a valid declaration and order already exist, so it cannot be obtained preemptively. And it does not replace the signed paperwork. It signals that the paperwork exists, but a responder acting on the device should still look for the document. When the declarant is transported by EMS, the identification device goes with them.⁸

What EMS Will Do When They Arrive

When EMS or another health care provider has actual knowledge of a signed out-of-hospital DNR (from the original document, a copy, or the identification device worn by or in the patient’s possession), the provider must withhold CPR.⁸ This is mandatory, not discretionary. The flip side: a DNR the responder does not know about does not bind them, so if nothing is apparent at the scene, the default is to resuscitate.

Four Situations Where Providers Must Perform CPR Anyway

The statute carves out four situations where the provider disregards the declaration and performs CPR:

The declarant is conscious and says they want to be resuscitated.
The provider reasonably believes in good faith that the declaration has been revoked.
The declarant’s attending physician, APRN, or physician assistant orders the provider to disregard the DNR.
The provider believes in good faith that honoring the DNR would cause a verbal or physical confrontation at the scene, and performs CPR to de-escalate.

The last one is unusual and reflects a practical reality: family members sometimes become aggressive when they disagree with the patient’s decision, and the law gives responders room to prioritize safety.⁸

Comfort Care Continues

A DNR does not mean the responders do nothing. The Indiana form states that the declaration does not affect the declarant’s right to receive comfort care or other medical treatment.⁴ EMS can still manage pain, provide oxygen for comfort, address wounds, and treat symptoms unrelated to cardiac or pulmonary arrest. The only things withheld are the resuscitative interventions themselves: chest compressions, defibrillation, advanced airway interventions, and cardiac drugs aimed at restarting the heart or lungs.

How to Revoke a DNR

The declarant can revoke the DNR at any time in any of three ways: by a signed and dated written statement, by physically destroying the declaration (or having someone else destroy it in the declarant’s presence), or by saying out loud that they want to revoke it.⁹ The revocation takes effect the moment it is communicated to a health care provider. No waiting period, no second signature.

Once a provider learns of the revocation, they add it to the medical file with the time, date, and place of revocation (if known) and when the physician, APRN, or PA was notified, and they write “VOID” on each page of the declaration and order in the file.⁹ Because verbal revocation is valid, families should understand that a conscious patient who tells a paramedic “I want to be resuscitated” has revoked the DNR on the spot.

Pregnancy Suspends the Declaration

An out-of-hospital DNR has no effect while the declarant is pregnant.¹⁰ A pregnant patient with a valid DNR will still receive CPR if she goes into cardiac or pulmonary arrest. The declaration is not revoked, only suspended. If the pregnancy ends, the existing declaration and order become effective again without re-execution.

DNR or POST — Which One You Need

Indiana has a broader end-of-life planning tool called Physician Orders for Scope of Treatment, or POST, governed by IC 16-36-6. An out-of-hospital DNR answers one question: CPR or not. A POST form covers several: the overall level of intervention (comfort measures only, limited interventions, or full treatment), whether to provide antibiotics, and whether to provide artificially administered nutrition.¹¹

A POST also applies in all settings, including hospitals and nursing homes, while the out-of-hospital DNR is by its nature limited to locations outside a hospital. Eligibility for POST is similar: an advanced chronic progressive illness or frailty, a terminal condition, or a condition where resuscitation would be unsuccessful or lead to repeated failure and death. No one can require a patient to complete a POST form as a condition of receiving health care.¹¹ If CPR is the only decision you want addressed, the out-of-hospital DNR is enough on its own.

Traveling Out of State

Indiana’s out-of-hospital DNR statute does not address whether the state recognizes DNR orders issued elsewhere, and IC 16-36-5 contains no reciprocity provision. Each state has its own forms, requirements, and identification systems, and an Indiana bracelet or form may not be recognized immediately by EMS in another state. Patients who travel frequently or split time between states should contact the EMS office or health department in each state to find out what documentation is needed. Some states may honor an out-of-state order informally, but that is thin cover when seconds count.

Penalties for Tampering

Indiana treats interference with a DNR declaration as a criminal offense. A person who knowingly or intentionally destroys a declaration without the declarant’s consent, or who forges a revocation of someone else’s declaration, commits a Class B misdemeanor,¹² which carries up to 180 days in jail and a fine of up to $1,000. The penalty applies whether the tampering is aimed at preventing a DNR from being honored or at forcing unwanted CPR on a patient.

Providers who act in good faith and in line with reasonable medical standards when withholding or performing CPR under the statute are protected from liability.¹³ That protection covers both honoring the DNR and performing CPR when one of the four override situations applies.

1
Indiana General Assembly. Indiana Code Title 16 Article 36 Chapter 5 – Section 16-36-5-10
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Indiana General Assembly. Indiana Code Title 16 Health 16-36-5-11
3
Indiana General Assembly. Indiana Code Title 16 Article 36 Chapter 5 – Section 16-36-5-12
4
Indiana Department of Health. State of Indiana Out of Hospital Do Not Resuscitate Declaration and Order
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Indiana General Assembly. Indiana Code Title 16 Article 36 Chapter 5 – Section 16-36-5-15
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Indiana General Assembly. Indiana Code Title 16 Article 36 Chapter 5 – Section 16-36-5-16
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Indiana General Assembly. Indiana Code Title 16 Article 36 Chapter 5 – Section 16-36-5-17
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Indiana General Assembly. Indiana Code Title 16 Article 36 Chapter 5 – Section 16-36-5-19
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Indiana General Assembly. Indiana Code Title 16 Article 36 Chapter 5 – Section 16-36-5-18
10
Indiana General Assembly. Indiana Code Title 16 Health 16-36-5-14
11
Justia. Indiana Code Title 16 Article 36 Chapter 6 – Physician Order for Scope of Treatment
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Indiana General Assembly. Indiana Code Title 16 Health 16-36-5-27
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Indiana General Assembly. Indiana Code Title 16 Article 36 Chapter 5 – Section 16-36-5-20