Massachusetts DNR Form: Do Not Resuscitate Order

Updated: Oct 29, 2026

What Is a Massachusetts DNR Order?

This order acknowledges medical staff that the patient (or their health proxy, parent) does not desire to use cardiopulmonary resuscitation (CPR) if the health indicators deteriorate. If the form is signed, the hospital personnel will be informed about that fact. However, if the patient or their representative revokes the DNR form, the request will be canceled, and the life of the said patient will be supported in the worst cases.

Which Procedures does the DNR Form Include?

Knowing exactly which treatments the order covers helps patients and families talk with the physician. The form covers situations of the patient’s cardiopulmonary attack. It restrains the Massachusetts Medical Association and EMS staff (emergency medical services) from giving the patient such treatment as:

• defibrillation
• assisted ventilation (breathing)
• chest compression (CPR)
• endotracheal intubation
• any types of stimulating drugs (stimulants)

However, the DNR form cannot stop the physicians from providing life-sustaining types of equipment (artificial subsistence and/or hydration, vitamins), treatments to reduce pain, delays in breathing, or bleeding (including internal bleeding), which are meant to make the death of the patient more comfortable.

Terms of the DNR Form Completion

The patient needs to consult with their primary physician. The question to ask is whether there are more risks or benefits of signing the form, thus, whether it is better to try to save one’s life or not. Note that each DNR form still provides comfortable health conditions.

If the patient is unable to sign the printable DNR form (or even decide about its completion independently), these decisions are made by their representative (parent, medical attorney). In Massachusetts, the form should be signed by both the physician and the patient (or by a representative on their behalf). Be careful to check the documentation with the local legislation.

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How to Fill the DNR Form

These steps follow the PDF this page hands out. Download it from the link near the top of the page, then print it and write by hand. You can also type into it with the online PDF editor. Complete the parts in order, from top to bottom. Most steps have a picture of that part of the form.

1. Get the form. Find, download, and print the Massachusetts DNR form.

2. Patient name, date of birth and address. In the first section, enter the patient's last, first and middle name or initial, then the date of birth, and tick the M or F box for gender. Add the street address, city, state and ZIP code below it.

3. Guardian or health care agent. If it applies, enter the last, first and middle name or initial of the guardian or health care agent in the fields below the address.

4. Patient, guardian or health care agent statement. Print the full name of the person signing and tick patient, guardian or health care agent. Then add the signature and the date.

5. Physician, nurse practitioner or physician assistant section. The physician, NP or PA completes this part. It has the date the order was issued, a choice for whether the order has an expiration date, and a line for that date. It also has their printed name, signature, address and telephone number, and the effective date of the form. From this moment, the medical staff starts to perceive the document as active.

6. Optional bracelet inserts. The bottom section is provided for the usage of the bracelet placed on or near the patient. The physician enters the patient’s personal information there, so later, the medical personnel will see it and prove that there is a DNR form completed by that person. Each insert has lines for the patient's name, gender, date of birth, expiration date and telephone number, plus a signature line.

How to Sign and Use the Massachusetts Do Not Resuscitate Order (DNR)

When the form is complete, keep it in a location where family members and medical staff can find it quickly. The steps below cover the original, the hospital copy and the people close to the patient, so everyone knows where the document is.

1. After completion of the form, please pay attention to save the original document to keep it in a safe place at home. In case the EMS staff comes into your house, they should be able to see that document to provide the established treatment.
2. If the person stays at the hospital, the document must be placed in the personal medical file or near the hospital bed.
3. Also, make sure the relatives and close friends of the patient know about the existence of the form.

Frequently Asked Questions

Who fills in each part of the Massachusetts DNR form?

The patient, guardian or health care agent completes the top of the form and the statement section. The physician, nurse practitioner or physician assistant completes the verification section and the optional bracelet inserts.

Can I fill out the form on a computer?

Yes. Download the PDF and type into it, or print it and write by hand. You can also answer a few questions with the Create My Document button at the top of the page.

What are the bracelet inserts for?

The bottom of the form has four optional bracelet inserts. Each one is filled in, signed, torn off, folded, trimmed and slipped into a bracelet.

Does the form have an expiration date?

The physician's section has a choice for whether the order has an expiration date, and a line for the date if there is one.

Where should I keep the completed form?

Keep the signed original in a safe place at home and tell close family members where to find it.

General information, not legal or tax advice.

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.