Indiana Do Not Resuscitate Order (DNR) Form

The Indiana Do Not Resuscitate (DNR) Form is a document that determines treatment applied to a patient in case of a heart or breath attack. People use the Indiana DNR form to avoid unnecessary resuscitation procedures because they will not help save their lives. Only patients who are in a terminal condition or have an incurable disease can complete this printable DNR form.

If the physician supports the patient’s decision about the irrelevance of implementation of cardiopulmonary resuscitation, all informed healthcare workers must follow prescribed terms. Not in all cases do physicians agree to sign the form. Where they disagree, they transfer this responsibility to other doctors. That is why you should consult with your physician before deciding on the DNR form.

Indiana DNR Form Singing Requirements

According to statutes from 16-36-5-1 to 16-36-5-28 of the Indiana Code, four people must sign the form to make it valid:

  • Patient or representative
  • Physician
  • Two witnesses

Regarding a representative of the patient, this person is allowed to sign the form on behalf of the patient only if their state is terminal and the patient cannot decide consciously.

There are several variants of people who can act on behalf of the patient in this situation:

  • Health care representative
  • Attorney-in-fact allowed to make health care decisions
  • Guardian

Concerning witnesses, they can be any person over 18 years old and able to confirm the voluntariness of the patient’s actions.

Revocation of Indiana DNR Form

Statute 16-36-5-18 of the Indiana Code regulates the revocation process of the DNR form. It says that the patient should follow one of these three ways to cancel the validity of the form:

  • Oral statement about revocation
  • Written and signed announcement
  • Destruction of the DNR form

After revocation, a physician must inform medical workers about the procedure and change prescriptions in the patient’s medical file. It will prevent situations of misunderstanding between health care service members.

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Download your fillable Indiana DNR form in PDF format.

How to Fill Out Indiana DNR Form

Indiana DNR Form filling out process is not time-consuming and is easy to complete by yourself. You need to print the form and enter the required data about the patient and physician into it. Once all fields are completed, four people must sign the form: physician, patient, and two witnesses.

Here you can find a step-by-step tutorial on the completion process of the Indiana DNR Form:

1. Enter the Date of the Form’s Execution

Fill in the date of the signing procedure in the first line of the Indiana DNR form.

step 1 to filling out the indiana dnr form - enter the date of the form’s execution

2. Sign the Form

Put your signature in the required field, which will confirm your readiness to make the DNR form applicable to you.

step 2 to filling out the indiana dnr form - sign the form

3. Write the Patient’s Full Name and Address

Identify the patient with their full name and residence under the signature.

step 3 to filling out the indiana dnr form - write the patients full name and address

4. Approve Validity of the Form by Witnesses

Witnesses have to sign the form and write their full names in the highlighted lines. Also, they should enter the date of signing next to their names.

step 4 to filling out the indiana dnr form - approve validity of the form by witnesses

5. Write in the Names of the Physician and the Patient

The physician should complete the last part of the form by entering their full name and that of the patient.

step 5 to filling out the indiana dnr form - write in the names of the physician and the patient

6. Fill in Personal Data About the Physician

The physician must sign the form, provide a printed name and the medical license number. Moreover, the doctor has to specify the date when the form was signed.

step 6 to filling out the indiana dnr form - fill in personal data about the physician

When you fill out all the fields of the form, you can be sure that the conditions described in it will be implemented. Make sure that all participants of the completion process provide correct data and sign the document.

Published: Oct 18, 2021