Out of Hospital DNR Form: What It Is and How to Get One

A standard DNR order in a hospital chart tells the medical team not to perform CPR if the patient's heart stops. But that order has no legal force outside the hospital walls. When paramedics arrive at a home, they follow a separate protocol — and without a specific out-of-hospital DNR form, they are legally required to begin full resuscitation regardless of what the patient or family says.

An out-of-hospital DNR (OOH-DNR) form bridges that gap. It's a physician-signed medical order that tells EMS personnel to withhold CPR and advanced cardiac life support when they respond to a call at the patient's home, nursing facility, or anywhere outside a hospital setting.

Why a Regular DNR Isn't Enough

Hospital DNR orders exist within the patient's medical chart. They apply only while the patient is admitted. The moment the patient is discharged — back home, to assisted living, to a family member's house — that hospital DNR has no effect on emergency responders.

Paramedics operate under standing medical protocols. Their default instruction is clear: if someone has no pulse and isn't breathing, start CPR. They cannot accept verbal instructions from family members, printed copies of hospital records, or even a signed advance directive as authorization to withhold resuscitation. They need a form they're trained to recognize.

This creates a scenario families rarely anticipate: a terminally ill parent who explicitly chose no resuscitation gets full CPR — chest compressions that can fracture ribs in an elderly patient, intubation, and emergency transport — because the right paperwork wasn't visible when 911 was called.

How an Out-of-Hospital DNR Works

The OOH-DNR is a standardized, state-issued form — typically printed on brightly colored paper (often orange, pink, or yellow) so first responders can identify it immediately.

The form must be:

• Signed by a licensed physician (nurse practitioners can sign in many states)
• Signed by the patient or their legally authorized healthcare proxy
• Present at the scene — on the refrigerator, in a visible binder, or worn as an OOH-DNR bracelet or necklace (accepted in some states)

When paramedics arrive and see the form, they verify the signatures, confirm the patient's identity, and follow the "do not resuscitate" order. They still provide comfort care — oxygen, pain management, suctioning — but they do not initiate CPR, defibrillation, intubation, or cardiac medications.

OOH-DNR vs. POLST: What's the Difference?

Many states have moved toward the POLST (Physician Orders for Life-Sustaining Treatment) model, which includes the OOH-DNR decision as Section A of a broader form. In these states, a completed POLST effectively replaces the standalone OOH-DNR because it covers resuscitation status plus additional treatment preferences (mechanical ventilation, feeding tubes, hospitalization level).

In states that use both forms:

If your state has an active POLST program, the POLST is usually the better choice because it addresses more clinical scenarios in a single form. Check the National POLST website or your state's health department to see which forms are currently in use.

Who Should Have an OOH-DNR

This form is appropriate for patients who:

• Have a terminal illness with a limited life expectancy
• Are experiencing advanced, progressive frailty
• Have made an informed decision — with their physician — that CPR would not meaningfully extend their life or would result in a quality of life they consider unacceptable
• Are receiving hospice care (hospice patients typically have an OOH-DNR as part of their care plan)

It is not a document for healthy older adults. A person with well-managed chronic conditions who wants aggressive treatment should not have an OOH-DNR. The decision should reflect a clinical reality — not family anxiety or premature planning.

How to Get the Form

1. Schedule a goals-of-care conversation with the patient's physician. This isn't a form you download and fill out independently — it requires a clinical assessment and physician signature.
2. Discuss the patient's prognosis honestly. The physician needs to assess whether CPR has a reasonable chance of restoring meaningful function or whether it would cause suffering without benefit.
3. Complete and sign the state-specific form. Your physician's office should have the current version, or you can find it through your state's department of health.
4. Post the original where EMS will see it. The most common location is on or near the refrigerator — many states specifically recommend this. Some states allow medical alert bracelets that indicate OOH-DNR status.
5. Inform all caregivers. Home health aides, family members, assisted living staff, and anyone who might call 911 needs to know the form exists and where it is.

The Form Can Be Revoked at Any Time

A patient who has capacity can revoke an OOH-DNR at any moment — verbally, in writing, or by destroying the form. If the patient tells paramedics "I want CPR," they are legally required to provide it regardless of what the form says.

This is important for families to understand: the OOH-DNR protects the patient's choice, not the family's preference. If the parent changes their mind during a crisis, their verbal instruction overrides the written form.

The End-of-Life Conversations and Advance Care Planning Toolkit includes a POLST readiness checklist and a guide to coordinating OOH-DNR decisions with the full advance care planning package — healthcare proxy, living will, and portable medical orders.