Free Wisconsin DNR Form

What the Wisconsin DNR Form Covers

The Wisconsin DNR form is a two-page document. Page 1 is the emergency care order itself. It lists the care emergency providers will and will not give, collects the patient's details, and has signature lines for the patient and the attending physician. Page 2 gives background information and instructions for completing the order.

The form also gives specific care instructions to health care providers who respond to emergency calls. If it is completed appropriately, emergency personnel should limit care as outlined.

The form's opening notice makes one point clear. Only the DNR bracelet identifies a patient to emergency medical service responders, and the form is used to request that bracelet.

Cardiopulmonary resuscitation (CPR) is the procedure that a DNR order declines. The form's background page describes cardiopulmonary resuscitation as a procedure used after cardiac arrest, when the heart stops, with cardiac massage, drugs and artificial ventilation to restore breathing and circulation. It is standard medical practice to perform CPR on anyone found in cardiac or respiratory arrest unless the attending physician directs otherwise. The DNR order is used to carry out the decision that CPR is not to be performed.

Page 1 prints two lists of emergency care. As appropriate, the emergency provider will:

• Clear the airway
• Administer oxygen
• Position the patient for comfort
• Splint
• Control bleeding
• Provide pain medication
• Provide emotional support
• Contact the hospice or home health agency involved in the patient's care, or the attending physician

The emergency provider will not:

• Perform chest compressions
• Insert advanced airways
• Administer cardiac resuscitation drugs
• Provide ventilator assistance
• Defibrillate

The form states that both signatures and dates, the patient's and the attending physician's, are required for the order to be valid.

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How to Fill Out Wisconsin DNR Form

The Wisconsin DNR form takes six steps to complete. The patient's details come first. The acknowledgment, the signer's title, the signature and date, the physician's section and the bracelet follow. Read the notice at the top of page 1 before you begin.

You can print the form, or fill in the downloaded PDF with our online PDF editor.

1. Enter the patient's details. Mark Male or Female and print the patient's name and date of birth. Then add the street address, city, state and zip code.

   

2. Read the acknowledgment paragraph. It sits just below the address lines. It says the document sets the level of care given by emergency personnel, including emergency health care facility staff, and that the request is made knowingly. It also says the signer releases future caregivers from liability for following it. It adds that the order can be revoked by removing or defacing the bracelet or by requesting resuscitation.

   

3. Circle who is signing. The signature line offers three titles: Patient, Legal Guardian, or Health Care Agent of an incapacitated patient. Circle the title of the person who will sign.

   

4. Sign and date. The person whose title is circled signs the line and writes the date signed.

   

5. Have the attending physician complete their part. The physician prints their name and telephone number, signs, and writes the date signed.

   

6. Get the bracelet. Page 2 says the attending physician or a designee either puts a plastic DNR bracelet on the patient's wrist or orders a metal one from the jeweler named there. A metal bracelet order includes a copy of the signed form, the jeweler's order form and payment.

   

What Wisconsin Law Says About DNR Orders

In Wisconsin, only an attending health care professional may issue a do not resuscitate order. Wis. Stat. §§ 154.19(3)(b) to 154.29 also set what the issuer must do, how a patient revokes the order, and the rules for DNR bracelets and penalties.^[1]

Issuing the Order

The statute says who may issue a Wisconsin DNR order in these words:

No person except an attending health care professional may issue a do-not-resuscitate order.

The statute also sets these conditions for issuing the order:

• The patient is a qualified patient, as the statute defines that term
• The order is in writing
• The health care professional does not know the patient to be pregnant^[1.1]

Except where the statute provides otherwise, the patient must also request the order, consent to it after receiving the required information, and sign it.^[1.1]

The attending health care professional, or a person the professional directs, must document in the patient's medical record the medical condition that qualifies the patient for the order. They must also give the patient written information about the resuscitation procedures the patient has chosen to forgo and the ways to revoke the order.^[1.1]

One condition that can make a person a qualified patient is a medical condition under which, if the person suffered cardiac or pulmonary failure, resuscitation would be unsuccessful in restoring cardiac or respiratory function, or the person would experience repeated cardiac or pulmonary failure within a short period before death (Wis. Stat. § 154.17(4)).^[2.1]

The guardian or health care agent of an incapacitated qualified patient may request the order for the patient, and consent to it and sign it after receiving the required information (Wis. Stat. § 154.225(2)).^[2.2]

Revoking the Order

A patient may revoke a do-not-resuscitate order at any time by any of the methods that Wis. Stat. § 154.21 lists.^[1.2] The form's instructions name three ways to revoke:

• Telling emergency personnel that the patient should be resuscitated
• Defacing or destroying the DNR bracelet
• Removing the DNR bracelet, or having another person remove it at the patient's request

The form adds that the order is not revoked when someone calls an ambulance. Ambulance personnel will honor the order and provide comfort care only.

DNR Bracelet Rules

According to the form, DNR bracelets tell the emergency medical services (EMS) personnel who respond that a DNR order exists. DNR bracelets also come with guidelines for comfort and supportive care short of CPR that emergency providers may give. The form says plastic and metal DNR bracelets are both available.

The department may not approve a DNR bracelet that a commercial vendor developed and distributed unless the vendor requires a doctor's order for the bracelet before giving it to a patient.^[1.3]

Under Wis. Stat. § 154.19(2)(b)1, one of the issuing steps is affixing to the patient's wrist a DNR bracelet that meets the specifications set under Section 154.27(1).^[2.3]

Penalties

Wis. Stat. § 154.29 sets penalties for misusing a DNR order or bracelet:

• Coercing, threatening or intimidating someone, directly or indirectly, into signing or issuing a DNR order brings a fine of up to $500, imprisonment for up to 30 days, or both
• Falsifying, forging or transferring a DNR bracelet to a patient, or concealing a revocation, with the intent to cause resuscitation to be withheld or withdrawn against the patient's wishes is a Class F felony. A responsible person who withholds personal knowledge of a revocation is also guilty of a Class F felony.^[1.4]

Frequently Asked Questions

A Wisconsin do not resuscitate order must be in writing, and the issuing health care professional must document the patient's qualifying medical condition in the medical record. The answers below cover documentation, pregnancy and revocation.^[1.1]

What must be documented if a patient has a DNR order?

The attending health care professional, or the person the professional directs, must document in the patient's medical record the medical condition that qualifies the patient for the DNR order. The professional must also make the order in writing.^[1.1]

Can a DNR order be issued for a pregnant patient?

Not when the health care professional knows the patient to be pregnant. The statute allows the order only when the professional does not know the patient to be pregnant.^[1.1]

Can a patient revoke a DNR order?

Yes. A patient may revoke the order at any time by any of the methods that the statute lists.^[1.2]

General information, not legal or tax advice.

Sources

1. Wis. Stat. §§ 154.19(3)(b) to 154.29.
   • 1.1 § 154.19(3)(b)
   • 1.2 § 154.21
   • 1.3 § 154.27
   • 1.4 § 154.29
2. Wis. Stat. ch. 154, subch. III
   • 2.1 § 154.17(4)
   • 2.2 § 154.225(2)
   • 2.3 § 154.19(2)(b)1