DNR Documentation Requirements
Yes, a specific Do-Not-Resuscitate (DNR) form must be signed—a living will alone is insufficient to establish DNR status in most clinical settings. While your patient's living will documents her general wishes and values, it does not constitute an actionable medical order that healthcare providers can follow in an emergency.
Why a Living Will Is Not Enough
A living will is a patient-generated advance directive that expresses general preferences and values for future care, but it lacks the specificity and legal standing of a physician order 1. Living wills are rarely sufficiently precise to dictate patient preferences in specific clinical situations, particularly regarding resuscitation decisions 1. Healthcare providers cannot act on a living will alone during a cardiopulmonary arrest—they need a physician-signed medical order.
What Form You Need
The specific form required depends on your state and practice setting:
POLST/MOLST Forms (Preferred)
- Physician Orders for Life-Sustaining Treatment (POLST) or Medical Orders for Life-Sustaining Treatment (MOLST) are the gold standard 2, 1
- These are actionable medical orders signed by a physician that convert patient preferences into specific clinical directives 1
- POLST forms are authorized in 23 states and have become the standard of care in skilled nursing facilities 2
- POLST more accurately conveys end-of-life preferences and is more likely to be followed by medical professionals than traditional advance directives alone 1
- These forms address not just resuscitation status but also preferences for hospital transfer, antibiotics, artificial nutrition, and other interventions 2
Standard DNR Order Forms
- If POLST is not available in your state, use your facility's standard DNR order form 3
- The DNR must be written as a legal order either in the patient's medical record or on a state-approved legal form 3
- Some states use terminology like "Allow Natural Death" (AND) instead of DNR, which focuses on what care will be provided rather than what is withheld 3
Out-of-Hospital DNR Orders
- If your patient wants DNR status to apply outside the hospital (at home, in nursing facilities), she needs a separate out-of-hospital DNR order 4
- These are legislated at the state level and must meet specific state requirements 4
- The form must be readily accessible to emergency medical services personnel
The Process You Should Follow
Review the living will with the patient to understand her values and preferences 5, 6
Conduct a goals-of-care discussion that addresses:
Complete the appropriate medical order form (POLST or DNR) based on this discussion 2, 1
Sign the form as the physician and ensure it is placed prominently in the medical record 2
Provide copies for all care settings where she receives care 6, 7
Document the discussion in the medical record, including her decision-making capacity, who participated in the discussion, and the rationale for the DNR order 8, 7
Critical Pitfalls to Avoid
Do not assume the living will serves as a DNR order—this is a common and dangerous misinterpretation that has led to compromised patient care 9. In one documented case, a living will was mistakenly treated as a DNR order, resulting in inappropriate withholding of care 9.
Ensure the form is accessible across all care settings. A DNR order in the hospital chart does not automatically transfer to outpatient settings, nursing homes, or emergency medical services 4. The patient should carry documentation of out-of-hospital DNR status at all times.
Clarify that DNR does not mean "do not treat" 3. A DNR order only applies to cardiopulmonary resuscitation and advanced cardiac life support—it does not preclude other appropriate treatments like antibiotics, pain management, chemotherapy, or surgery 3.
State-Specific Considerations
Check your state's specific requirements, as DNR legislation varies significantly 4. Some states have online registries (like Oregon's system) where end-of-life preferences can be documented and accessed by healthcare providers with internet connectivity 4. If available in your state, enrollment in such a registry provides an additional layer of protection for ensuring her wishes are honored.
Reassessment
DNR orders should be reassessed regularly as the patient's condition or preferences change 5, 6. Schedule periodic discussions to confirm the order remains consistent with her goals, particularly after hospitalizations, changes in functional status, or new diagnoses 5.