Texas Do Not Resuscitate (DNR) Order FormTexas Do Not Resuscitate (DNR) Order Form
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Figure: 25 TAC §157.25 (h)(2)

OUT-OF-HOSPITAL DO-NOT-RESUSCITATE (OOH-DNR) ORDER

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TEXAS DEPARTMENT OF STATE HEALTH SERVICES
This document becomes effective immediately on the date of execution for health care professionals acting in out-of-hospital settings. It remains in effect until
the person is pronounced dead by authorized medical or legal authority or the document is revoked. Comfort care will be given as needed.
Male

Date of birth

Person's full legal name

Female

A. Declaration of the adult person: I am competent and at least 18 years of age. I direct that none of the following resuscitation measures be initiated or continued for me:
cardiopulmonary resuscitation (CPR), transcutaneous cardiac pacing, defibrillation, advanced airway management, artificial ventilation.
Printed name

Date

Person's signature

B. Declaration by legal guardian, agent or proxy on behalf of the adult person who is incompetent or otherwise incapable of communication:
proxy in a directive