Kansas Do Not Resuscitate Order (DNR) Form

The Kansas DNR form is a legal document that allows a person to make an order for the doctors not to use any future resuscitation procedures on them. This means that when your heart stops, or you are not breathing, the doctors would not have any right to use cardiopulmonary resuscitation (CPR) on you.

In accordance with §65-4943, there is a need not only for the patient but also for their physician and a witness to sign the document for it to become legally powered.

The usual case under which patients decide to make such a document is when they have some serious terminal illnesses, for which there would not be any use from CPR.

If you are a completely healthy patient or do not have any serious conditions, it might also be good for you to create such a printable DNR form, as it could actually save your life.

Our advice for you would be to talk to someone before making such a life-or-death decision. It might be very helpful to speak with your physician, as they might have some insights into your specific situation. A lawyer might also be necessary for you, as well as talking with your close ones.

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Download your fillable Kansas DNR form in PDF format.

How to Fill Out the Kansas DNR Form

Now, as we are acquainted with what this DNR form means, let us go through some details on how you would need to fill it out.

This form should be filled out in advance, as in any other case, doctors and paramedics would not know what they can or cannot do. Thereby, no blame can be put on them if you later decide that you did not want such procedures.

1. Fill out Personal Details

The first part of the Kansas DNR form would require you, as the patient, to fill out your full name and read the part that follows this step.

step 1 to filling out the kansas dnr form - fill out personal details

2. Get the Signatures of the Patient and Witnesses

In the second part, signatures of the patient and the witness are required, together with the date on which the document is signed. Both should fill it in near their signatures.

step 2 to filling out the kansas dnr form - get the signatures of the patient and witnesses

3. Fill In Info About Physicians

The third and last part includes some information regarding your physician, who would have to read the document and sign it if everything is correct.

Here is what the physician should put down:

  • The signature
    step 3 to filling out the kansas dnr form - the signature
  • The date
    step 3 to filling out the kansas dnr form - the date
  • The current address
    step 3 to filling out the kansas dnr form - the current address
  • Facility or agency name
    step 3 to filling out the kansas dnr form - facility or agency name

After that, your DNR form is filled and has the legal power to be used in emergency situations. The pages that go after that are additional.

If you want to revoke your DNR form, here is the place where you would need to put your signature and the date when it was filled out.

step 3 to filling out the kansas dnr form - fill in info about physicians 1

Do not pay any serious attention to all of the following pages: they are simply notes that you may or may not need. All that was mandatory to be filled is already done.

step 3 to filling out the kansas dnr form - fill in info about physicians 2

Published: Oct 18, 2021