DNR Form Witness Requirements
DNR orders that refuse life-sustaining treatment must be in writing and witnessed according to most guidelines, though specific requirements vary by jurisdiction and clinical setting. 1
Legal and Documentation Requirements
Written Documentation Mandate
- All DNR orders must be written by a licensed physician in the patient's medical record—oral DNR orders are not acceptable. 1
- The attending physician must document the rationale for the DNR order, specific limitations of care, and discussions with the patient, surrogate, and family. 1
Witness Requirements for Advance Decisions
- When a DNR order is part of an advance decision to refuse life-sustaining treatment, it must be in writing, must be witnessed, and must explicitly state that it applies even if life is at risk. 1
- If the patient is unable to write the document themselves, it can be drafted by another person in the presence of an independent witness and the treating physician, with both the witness and physician signing and dating the document. 1
Standard DNR Orders vs. Advance Directives
The witness requirement differs based on the type of order:
- Standard DNR orders written during hospitalization by the attending physician do not require the patient or family to provide a witnessed signature. 1
- These orders require only the physician's written order with appropriate documentation of discussions. 1
- However, advance decisions made ahead of time that refuse life-sustaining treatment (including CPR) must meet the stricter witnessed signature requirement. 1
Regional Variations and Policy Differences
New York State Requirements
- Some jurisdictions like New York State have historically required signed consent from patients or surrogates for DNR orders, though this creates barriers to timely discussions. 2
- Research demonstrates that eliminating signed consent requirements in favor of witnessed verbal consent reduces surrogate stress (mean stress scores decreased from 23.6 to 17.3, p=0.02) and improves physician confidence in obtaining DNR orders. 2
- The policy change to witnessed verbal consent was well-received by 98% of house officers, 59% of attendings, and 79% of nurses. 2
Standard Hospital Practice
- Most hospital policies require the attending physician to write the DNR order with documentation but do not mandate patient or family signatures with witnesses. 1
- The emphasis is on thorough documentation of capacity, discussions, and the decision-making process rather than formal witnessed signatures. 3
Essential Documentation Components
Regardless of witness requirements, all DNR orders must include:
- The patient's capacity at the time of decision-making and the date of implementation. 3
- Specific interventions to be withheld (chest compressions, intubation, mechanical ventilation, defibrillation, vasopressors). 1, 3
- Explicit statement that DNR does not affect other treatments unless specifically noted. 1, 3
- Documentation of prognosis discussions and the patient's understanding. 4
Common Pitfalls to Avoid
- Do not confuse standard physician-written DNR orders (which typically don't require witnessed patient signatures) with advance directives refusing life-sustaining treatment (which do require witnesses). 1
- Avoid vague language—be explicit about which interventions are withheld and which continue. 3
- Ensure DNR documentation is portable and accessible to all healthcare team members through bedside orders, wallet cards, or identification bracelets. 4
- Remember that requiring signed consent can create barriers to timely end-of-life discussions and increase surrogate stress. 2, 5