Free Indiana Out of Hospital DNR Order Form

Indiana DNR Form Signing Requirements

Three parties act on an Indiana out of hospital DNR: the declarant, at least two competent witnesses, and the health care professional who issues the order. The form has a signature block for each of them, and the Indiana Code sets a rule for the declarant's signature, the witnesses and the order.

• The declarant signs the declaration, or another person signs in the declarant's presence and at the declarant's express direction.^[1]
• The declaration must be signed in the presence of at least two competent witnesses.^[1]
• The order may be issued only by the declarant's attending physician, advanced practice registered nurse, or physician assistant.^[1]

Each witness also makes a statement about their ties to the declarant. In the statute's wording:

I am not entitled to any part of the declarant's estate or directly financially responsible for the declarant's medical care.

A competent witness must be at least 18 and cannot be the person who signed the declaration for the declarant, the declarant's parent, spouse or child, a person entitled to any part of the declarant's estate, or a person directly financially responsible for the declarant's medical care (Ind. Code § 16-36-5-2).^[2]

An attending physician who does not issue an out of hospital DNR order for a qualified person may transfer the patient to another physician, who may issue the order (Ind. Code § 16-36-5-13(a)).^[2]

A health care provider must withhold or discontinue CPR to a patient in an out of hospital location if the provider has actual knowledge of an original or a copy of a signed out of hospital DNR declaration and order executed by the patient, or of an out of hospital DNR identification device the patient wears or has (Ind. Code § 16-36-5-19(a)).^[2]

Revocation of Indiana DNR Form

The declarant may revoke an Indiana out of hospital DNR declaration and order at any time. The three ways to revoke it are a signed, dated writing, physical cancellation or destruction of the declaration and order, or an oral expression of intent to revoke.^[1]

• A signed, dated writing.
• Physical cancellation or destruction of the declaration and order by the declarant, or by another person in the declarant's presence and at the declarant's direction.
• An oral expression by the declarant of intent to revoke.

In practice, it helps to tell your physician and anyone who holds a copy that you revoked the order, so every copy matches your wishes.

Create a Personalized Indiana DNR Order Form online in under 5 minutes!

Create and Print Online Now

How to Fill Out Indiana DNR Form

Create the Indiana DNR form online with the FormsPal builder, or print the PDF and fill it in by hand. The declarant, the witnesses and the physician each complete their own part of the form, so follow the parts below in the order they appear on the page.

1. Enter the date of the declaration. Fill in the day, month and year on the first line, which begins "Declaration made this".

   

2. Read the declaration. Read the "I declare" paragraphs. Nothing is filled in here. They say that the declarant's attending physician has certified the declarant as a qualified person, and that CPR is to be withheld or withdrawn if cardiac or pulmonary failure happens outside an acute care hospital.
3. Sign as the declarant. The declarant signs on the "Signature of declarant" line. Another person may sign in the declarant's presence and at the declarant's express direction.^[1]

   

4. Print the name and city and state of residence. Print the declarant's full name on the "Printed name of declarant" line, then add the city and state of residence under the signature. The form asks for the city and state, not a street address.

   

5. Have both witnesses complete their blocks. Each of the two witnesses reads the printed statement, signs on the "Signature of witness" line, prints a name and enters the date (month, day, year). The statement says the witness knows the declarant personally, is at least 18 and is not the declarant's parent, spouse or child.

   

6. Complete the physician's order. In the order block, fill in the blanks in the sentence that begins "I, ___, the attending physician of ___".

   

7. Sign the order. The physician signs on the "Signature of attending physician" line, prints a name, enters the medical license number and adds the date (month, day, year).

   

When every part is complete, keep the signed original where family and care providers can find it. Related Indiana health care forms on FormsPal include the Indiana living will and the Indiana medical power of attorney.

Frequently Asked Questions

Does a DNR need a doctor's order?

Yes, the order comes from a health care professional. In Indiana, an out of hospital DNR order may be issued only by the declarant's attending physician, advanced practice registered nurse, or physician assistant.^[1] The declarant signs the declaration, and one of those professionals issues the order.

General information, not legal or tax advice.

Sources

1. Ind. Code § 16-36-5-11.
2. Ind. Code ch. 16-36-5.

Mara Erlach

Writer & Attorney

Mara has been practicing estate planning and trust law in California since 2003, taking pride in helping clients of all backgrounds and asset profiles form a complete and customized estate plan. Her specialties are: estate planning, wills and trusts, trust and probate administration.