Who Must Sign? DNR Signature Requirements by State (2026)
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In a nutshell, a do not resuscitate (DNR) order is only legally valid when the right people sign it — and those requirements vary significantly from state to state. Some states require just a physician's signature alongside the patient's; others demand two witnesses, a notary, or authorization from a designated surrogate. Understanding what your state requires is the first step to ensuring a DNR is honored when it matters most.
This guide breaks down the signature and execution requirements for DNR orders across all 50 states and the District of Columbia, based on each state's current statutes and administrative rules.
Table of Contents
What Is a DNR Order — and Why Do Signatures Matter?
A do not resuscitate order, sometimes called a "do not attempt resuscitation" (DNAR) order or an "allow natural death" (AND) order, is a medical directive that instructs healthcare providers and emergency personnel not to perform cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest. CPR includes chest compressions, defibrillation, endotracheal intubation, artificial ventilation, and related procedures.
A DNR order is only as valid as the process used to create it. If the wrong parties sign, or required parties don't sign at all, emergency medical personnel may be legally unable to honor the document. Depending on the state, a defective DNR could be disregarded entirely, and resuscitation efforts would proceed by default.
Most states presume consent to CPR in the absence of a valid contrary order. That means getting the signatures right is not a formality, it is the difference between the order being followed and it being set aside.
The Key Parties Who May Need to Sign
Across the states where specific requirements exist, DNR signature requirements typically involve some combination of the following parties:
- The attending physician (and in some states an advanced practice registered nurse or physician assistant) is required in virtually every state that has a formal DNR statute. In many states, the physician's signature alone is not sufficient — the patient or an authorized representative must also sign.
- The patient themselves, when competent and of legal age (typically 18 or older), provides the consent that makes the DNR order legally grounded in the individual's own wishes. Many states allow the patient to sign a DNR declaration or consent form independently.
- A legally authorized representative — which may be a healthcare proxy, agent under a durable power of attorney for health care, court-appointed guardian, or a designated surrogate — can sign on behalf of a patient who lacks decision-making capacity.
- Witnesses are required in several states, usually two, and are often subject to disqualifying conditions: they cannot be related to the patient by blood or marriage, cannot be heirs to the patient's estate, and cannot be financially responsible for the patient's medical care.
- A notary public may substitute for witnesses in certain states, or may be required in addition to witnesses depending on the form used.
Signature Requirements at a Glance
The table below covers all 50 states and the District of Columbia. States that do not identify a specific standalone out-of-hospital DNR statute are noted as such — those states typically rely on advance directives or other estate planning documents when making resuscitation decisions.
| State | Patient/Surrogate Signature | Physician/Clinician Signature | Witnesses Required | Notary Option | Applicable Statute(s) |
|---|---|---|---|---|---|
| Alabama | Yes — patient if competent; healthcare proxy, surrogate, or attorney-in-fact if not | Yes — attending physician | Yes | No | Ala. Code § 22-8A-4.1 |
| Alaska | Yes — principal (patient); 2 witnesses personally known to principal | No separate DNR statute; governed by advance directive framework | Yes | Yes | Alaska Stat. Ann. § 13.52.010 |
| Arizona | Yes — patient (or mark); agent or guardian if patient is no longer competent | Yes — licensed healthcare provider | Yes | No | Ariz. Rev. Stat. Ann. § 36-3251 |
| Arkansas | Yes — patient, healthcare proxy, or legal guardian | Yes — attending physician | Yes | Yes | Ark. Code Ann. § 20-17-202; Ark. Admin. Code 007.28.5-V |
| California | Yes — patient or legally recognized healthcare decision-maker | Yes — physician, NP, or PA (under physician supervision) | Yes | No | Cal. Prob. Code § 4780 |
| Colorado ("CPR Directive") | Yes — patient, healthcare proxy, or legal guardian | Yes — attending physician | Yes | — | C.R.S. § 15-18.6-102 |
| Connecticut | Yes — patient or authorized representative (per DPH regulation) | Yes — physician or APRN | Yes | Per DPH regulation | Conn. Gen. Stat. Ann. § 19a-580d |
| Delaware | No specific out-of-hospital DNR statute identified | — | — | — | — |
| District of Columbia | No specific out-of-hospital DNR statute identified | — | — | — | — |
| Florida | Yes — patient, surrogate, proxy, guardian, or agent with express healthcare authority | Yes — physician, osteopathic physician, autonomous APRN, or PA | Yes | No | Fla. Stat. Ann. § 401.45; Fla. Admin. Code r. 64J-2.018 |
| Georgia | Yes — adult patient (oral or written); authorized person on behalf of incapacitated patient | Yes — attending physician (printed name and signature required on out-of-hospital form) | Yes | No | Ga. Code Ann. §§ 31-39-4, 31-39-6.1 |
| Hawaii | Yes — patient or legally authorized representative | Yes — healthcare provider | Yes | No | Haw. Rev. Stat. Ann. § 327K-1 |
| Idaho | No separate patient signature requirement — presumption of CPR consent overridden by valid POST device, advance directive, or physician DNR order | Yes — licensed independent practitioner | Yes | No | Idaho Code Ann. § 39-4514 |
| Illinois | Yes — patient, legal guardian, POA agent, or surrogate decision-maker | Yes — qualified healthcare practitioner | Yes | No | 755 Ill. Comp. Stat. Ann. 40/65 |
| Indiana | Yes — declarant or authorized representative (in presence of 2 witnesses) | Yes — attending physician, APRN, or PA | Yes | No | Ind. Code Ann. §§ 16-36-5-11, 16-36-5-12, 16-36-5-15 |
| Iowa | No patient signature required on the order | Yes — attending physician or PA | Yes | No | Iowa Code Ann. § 144A.7A |
| Kansas | Yes — declarant or another at their direction | Yes — attending physician or PA | Yes | No | Kan. Stat. Ann. §§ 65-4942, 65-4943 |
| Kentucky | Yes — patient, surrogate, or responsible party (e-signature permitted) | Yes — physician (original or e-signature) | Yes | No | Ky. Rev. Stat. Ann. §§ 311.623, 311.6225 |
| Louisiana | Yes — declarant in presence of 2 witnesses; authorized family member if patient incapacitated | No separate physician signature on declaration | Yes | No | La. Stat. Ann. §§ 40:1151.2, 40:1151.4 |
| Maine | Yes — principal (in-person signature only; no electronic signatures) | No separate physician signature | Yes | No | Me. Rev. Stat. Ann. tit. 18-C, § 5-803 |
| Maryland | Yes — patient or authorized representative (per MIEMSS protocol) | Yes — per MIEMSS/State Board of Physicians protocol; MOLST equivalent | Yes | Per protocol | Md. Code Ann., Health-Gen. § 5-608 |
| Massachusetts | No specific out-of-hospital DNR statute identified | — | — | — | — |
| Michigan | Yes — declarant, patient advocate, or person at declarant's direction | Yes — attending physician | Yes | No | Mich. Comp. Laws Ann. §§ 333.1053, 333.1056 |
| Minnesota | No specific out-of-hospital DNR statute identified | — | — | — | — |
| Mississippi | No specific out-of-hospital DNR statute identified | — | — | — | — |
| Missouri | Yes — patient or patient's representative | Yes — attending physician | Yes | No | Mo. Ann. Stat. § 190.600 |
| Montana | Yes — declarant or another at their direction | No separate physician signature on declaration | Yes | No | Mont. Code Ann. § 50-9-103 |
| Nebraska | No specific out-of-hospital DNR statute identified | — | — | — | — |
| Nevada | Yes — patient in writing while capable of informed decision; parent/guardian and minor (if sufficiently mature) for minors | Yes — physician or APRN | Yes | No | Nev. Rev. Stat. Ann. § 450B.510 |
| New Hampshire | Yes — patient, agent, or surrogate; 2nd practitioner concurrence required if no surrogate available | Yes — attending practitioner | Yes | No | N.H. Rev. Stat. Ann. § 137-J:26 |
| New Jersey | Implied through advance directive or physician determination | Yes — attending physician | Yes | No | N.J. Stat. Ann. § 26:2H-68 |
| New Mexico | No specific out-of-hospital DNR statute identified | — | — | — | — |
| New York | No specific out-of-hospital DNR statute identified | — | — | — | — |
| North Carolina | No specific out-of-hospital DNR statute identified | — | — | — | — |
| North Dakota | No specific out-of-hospital DNR statute identified | — | — | — | — |
| Ohio | No separate patient signature on order form | Yes — authorized healthcare provider (physician, APRN, or PA) | Yes | No | Ohio Rev. Code Ann. §§ 2133.21, 2133.23; Ohio Admin. Code 3701-62-04 |
| Oklahoma | Yes — patient or representative; or attending physician certification (for incapacitated patients without representative) | Yes — attending physician (Certification of Physician section) | Yes | No | Okla. Stat. Ann. tit. 63, §§ 3131.4, 3131.5 |
| Oregon | No specific out-of-hospital DNR statute identified | — | No | — | — |
| Pennsylvania | Yes — patient if capable; surrogate if not | Yes — attending physician (with printed name, emergency phone, and date) | Yes | No | 20 Pa. Stat. and Cons. Stat. Ann. §§ 5483, 5484 |
| Rhode Island | No specific out-of-hospital DNR statute identified | — | — | — | — |
| South Carolina | Physician order only for out-of-hospital form | Yes — attending physician (printed name, signature, phone, and date) | Yes | No | S.C. Code Ann. § 44-78-15 |
| South Dakota | No specific out-of-hospital DNR statute identified | — | — | — | — |
| Tennessee | No specific patient signature requirement identified | Yes — attending physician | Yes | Per TDH rule | Tenn. Code Ann. § 68-11-224 |
| Texas | Yes — competent patient with 2 witnesses; proxy, agent, or qualified relative with 2 witnesses if patient incompetent | Yes — attending physician | Yes | Yes | Tex. Health & Safety Code Ann. §§ 166.082, 166.083 |
| Utah | No specific out-of-hospital DNR statute identified | — | — | — | — |
| Vermont | Yes — patient or person giving informed consent (named on form); 2nd clinician required for futility-based orders | Yes — clinician (MD, DO, APRN, or PA) | Yes | No | Vt. Stat. Ann. tit. 18, § 9708; Vt. Admin. Code 12-5-15 |
| Virginia | Yes — patient; or authorized representative if patient is minor or lacks capacity | Yes — physician with bona fide physician-patient relationship | Yes | No | Va. Code Ann. §§ 54.1-2982, 54.1-2987.1 |
| Washington | No specific out-of-hospital DNR statute identified | — | No | — | (Pre-publication: verify current Washington framework) |
| West Virginia | Yes — patient and/or surrogate (both signatures on out-of-hospital card form) | Yes — physician, PA, or APRN | Yes | No | W. Va. Code Ann. § 16-30C-6 |
| Wisconsin | No specific patient signature requirements identified | Yes — per DHS subchapter requirements | Yes | Per DHS rule | Wis. Stat. Ann. § 154.17 |
| Wyoming | No specific out-of-hospital DNR statute identified | — | — | — | — |
What Happens If Requirements Aren't Met?
A DNR order that does not satisfy the applicable state's execution requirements may be deemed invalid by emergency medical personnel. If any doubt exists about the validity of a DNR, most state laws direct healthcare providers to proceed with resuscitation. This default-to-resuscitation rule means defects in execution — a missing signature, an improper witness, or a form not matching the state's required format — can have life-altering consequences that cannot be undone.
Several states specifically address this scenario. Florida, Iowa, and Ohio explicitly instruct emergency personnel to provide resuscitation when validity is uncertain. Indiana places the burden of proving invalidity on any party who challenges a properly signed DNR.
How to Ensure Your DNR Is Honored
Getting the signatures right is necessary, but it is not the only factor in ensuring a DNR is honored. To give the document the best chance of being followed, consider the following steps.
Use a state-approved form. Most states that have specific DNR statutes also specify an approved form. LegalNature provides legally compliant forms for each state and the District of Columbia.
Keep the document accessible. Many states require that the document accompany the patient during transport, be posted prominently in the home, or be maintained in an accessible location. A DNR stored in a filing cabinet where emergency personnel cannot find it may as well not exist.
Inform your healthcare providers. Place a copy in your medical record with your primary care physician, any specialist treating a relevant condition, and any assisted living facility or home health agency involved in your care.
Consider supplemental identification. Many states authorize DNR bracelets and necklaces as supplemental or alternative identification. In Florida, the bracelet is specifically noted as requiring special treatment — personnel must honor it even if they cannot locate the paper form. In Georgia, Michigan, Ohio, and several other states, wearing approved identification can reinforce the written order.
Review and update the document. As your health and wishes change, keep any prior executed DNR orders in mind and update or revoke them as needed. A DNR order that reflects outdated wishes or is issued by a physician no longer involved in the patient's care may raise questions about its currency.
Consulting with an attorney is highly recommended when creating or reviewing end-of-life documents, since each state has its own specific requirements and the consequences of an invalid document can be irreversible.
Frequently Asked Questions
Does a DNR order expire?
In most states, a DNR order remains valid indefinitely until it is revoked or the patient dies. Arizona, Georgia, Texas, and Virginia explicitly state that the order remains effective until revoked. Some states recommend periodic review, but a failure to review does not automatically invalidate the order.
Can a patient revoke a DNR?
Yes. In virtually every state, a competent patient can revoke a DNR at any time. Revocation may be oral (expressing a desire to be resuscitated to healthcare personnel at the scene), written, or by physical destruction of the document. In Texas, a patient may also revoke by removing a DNR identification device. In Florida, simply not presenting the form to EMS personnel constitutes a revocation.
Can a family member sign a DNR for a patient who cannot sign for themselves?
In most states, yes — but only if that family member qualifies under the state's priority hierarchy for healthcare decision-making. Most states recognize agents under a healthcare power of attorney or medical power of attorney, healthcare proxies, and court-appointed guardians. Some states, including Louisiana, Iowa, and West Virginia, provide a specific priority list of family relationships. A family member who does not have legal authority to make healthcare decisions generally cannot execute a binding DNR.
Is a DNR from another state valid if I travel or move?
Some states recognize out-of-state DNR orders; others do not. When relocating or traveling with a serious illness, it is wise to have the document reviewed for validity in the new state.
Is a DNR the same as an advance directive?
No. A DNR order and an advance directive are distinct documents that serve different purposes. An advance directive (such as a living will or healthcare power of attorney) records a person's general healthcare wishes and may appoint an agent to make decisions. A DNR order is a specific, immediately actionable medical order to withhold CPR. California, Florida, and Virginia's statutes explicitly state that a DNR is not an advance directive. That said, in many states the existence of an advance directive directing no CPR can be the basis for a physician to issue a DNR order.
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Creating or updating end-of-life documents is one of the most important steps you can take to ensure your wishes are honored. If you are considering a DNR order, you may also want to review LegalNature's living will, healthcare power of attorney, and advance directive documents, all of which work together as part of a complete estate and healthcare planning strategy.