Free Kansas DNR Order Form

Kansas DNR Order Requirements

Under Section 65-4943 of the Kan. Stat. Ann., a "do not resuscitate" directive must be in writing, signed and dated. The person making the declaration signs it, or another person signs in the declarant's presence and at the declarant's expressed direction.^[1]

A "do not resuscitate" directive shall be: in writing; signed by the person making the declaration, or by another person in the declarant's presence and by the declarant's expressed direction; dated;

The statutory directive form in Section 65-4942 of the Kan. Stat. Ann. has three signature blocks.^[2]

• The person making the declaration signs under the statement "I hereby agree to the "Do Not Resuscitate" (DNR) directive."
• The attending physician or physician assistant signs and dates a separate line.
• A revocation provision reads "I hereby revoke the above declaration." and has its own signature and date lines.

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How to Fill Out the Kansas DNR Form

Create your DNR order online with the builder above, or download the PDF to fill in by hand. The fillable part of the template is the Pre-Hospital DNR Request Form on page 4. It has four parts, and each step below follows one of them in order, with a screenshot of sample entries.

To type into the PDF instead, use our online PDF editor.

The screenshots under each step show the FormsPal Kansas DNR order template filled with sample entries in blue, so you can see where each answer goes. The names, addresses, dates and amounts are examples only.

1. Write the patient's name on the request line. On page 4, write your full name after "I," at the top, under the K.S.A. 65-4942 header. The short statements below it say what a DNR means and that you may revoke the order at any time.

   

2. Sign and date the form as the patient. Sign on the Signature line under "I hereby agree to the "Do Not Resuscitate" (DNR) directive" and add the date.

   

3. Have the attending physician sign, then add the address and facility. The physician signs and dates the line under the statement affirming that the order is the patient's expressed wish. The address and the facility or agency name go on the lines below. A footnote marked with an asterisk explains when the physician's signature is not required.

   

4. Use the revocation provision only to cancel the order. To revoke, sign and date under the statement "I hereby revoke the above declaration."

   

After You Sign a Kansas DNR Order

Once the form is signed and dated, the remaining work is practical. A DNR order only helps if the people who care for you know it exists and can find it quickly. The steps below are common practice, not Kansas legal requirements.

• Keep the signed original in one known place, such as a folder with your other medical papers.
• Give copies to your physician and to the family members closest to you.
• Tell those people where the original is kept and what the order says.
• Review the order if your health or your wishes change. The revocation provision on the form is how you cancel it.

DNR Order vs. Living Will in Kansas

A DNR order covers one decision. It says whether CPR is started if your heart stops or you stop breathing. A living will is a separate document where people record wider wishes about health care near the end of life. Some people keep both, and each is signed on its own.

If you also want to record those wider wishes, see our Kansas living will form. To name someone who can act for you in other matters, see our Kansas power of attorney forms. Living in more than one state? Browse our DNR forms for every state.

Frequently Asked Questions

A DNR order is complete in Kansas when it is in writing, signed and dated. The questions below show where to sign the form and what the statutory form contains, using the wording of the Kansas statutes cited on this page.

How do you sign DNR papers in Kansas?

Sign on the Signature line under the statement "I hereby agree to the "Do Not Resuscitate" (DNR) directive."^[2] The order must also be dated. Either you sign it, or another person signs in your presence and at your expressed direction.^[1]

What are the requirements for a DNR order in Kansas?

A Kansas DNR order must be in writing, signed and dated.^[1] The statutory form adds three parts.^[2]

• A signature line for the person making the order.
• A signature and date line for the attending physician or physician assistant.
• A revocation provision that reads "I hereby revoke the above declaration."

The physician's signature is not required for a member of a church or religion that treats illness by spiritual means through prayer alone.^[2]

Can someone else sign a DNR order for me in Kansas?

Yes, in one situation. The statute allows another person to sign in the presence of the person making the declaration and at that person's expressed direction. The order must still be in writing and dated.^[1]

Does a Kansas DNR order have to be dated?

Yes. Section 65-4943 lists the date next to writing and signature as the three basic elements of the order.^[1] The statutory form also has a date line beside the physician's signature and beside the revocation provision.^[2]

How do you revoke a DNR order in Kansas?

The statutory form includes a revocation provision. It reads "I hereby revoke the above declaration." and has its own signature and date lines.^[2]

General information, not legal or tax advice.

Sources

This page relies on two sections of the Kansas Statutes Annotated. Section 65-4943 sets out what a do not resuscitate order must be, and Section 65-4942 contains the statutory form with its signature lines and revocation provision.

1. Kan. Stat. Ann. 65-4943.
2. Kan. Stat. Ann. § 65-4942.

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.