Massachusetts Do Not Resuscitate Order (DNR) Form

Massachusetts Do Not Resuscitate (DNR) form is the document that allows the patient to express their desire to stop living in the case they do not want to let doctors rescue them when their heart or lungs cease to work. 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?

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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Download your fillable Massachusetts DNR form in PDF format.

How to Fill the DNR Form

  • Find, download, and print the Massachusetts DNR form.
  • In the first section, insert the patient’s contact information, including the first, last, and middle name, date of birth, and tick the box with the gender. Next, follow it by the full patient’s home address, the city and the state of dwelling, and the ZIP code.

step 1 to filling out the massachusetts dnr form

  • If applicable, the following fields are provided for information about the medical proxy, including their full name.

step 2 to filling out the massachusetts dnr form

  • The last field for the patient or their representative to fill includes inserting their full printed names (check whose name is written by ticking the correct box), one’s signature, and the date of the document’s completion.

step 3 to filling out the massachusetts dnr form

  • The following field should be completed by the physician. They provide information on the date of the form’s creation and whether it has an expiration date (follow the instructions in the document to complete it successfully). Further, the doctor provides their printed name, signature, their home address, and telephone number. After that, enter the effective date of the form. From this moment, the medical staff starts to perceive the document as active.

step 4 to filling out the massachusetts dnr form

  • 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.

step 5 to filling out the massachusetts dnr form

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. If the person stays at the hospital, the document must be placed in the personal medical file or near the hospital bed.

Also, make sure the relatives and close friends of the patient know about the existence of the form.

Published: Oct 18, 2021