Texas Out-of-Hospital DNR: How the OOH-DNR Works Outside the ER

A standard hospital DNR ("No Code" order) only applies while you're admitted under a physician's care. The moment you leave the hospital — whether you go home, to a nursing facility, or to a clinic — that order has no legal effect on the paramedics who respond if you stop breathing.

Texas addresses this with the Out-of-Hospital Do-Not-Resuscitate order, authorized under Health and Safety Code Chapter 166, Subchapter C, including Section 166.083. It's the only document that legally directs EMS personnel and first responders to withhold resuscitation measures outside a hospital setting.

What the OOH-DNR Covers

When EMS encounters a patient with a valid OOH-DNR, they must withhold:

• Cardiopulmonary resuscitation (CPR)
• Transcutaneous cardiac pacing
• Defibrillation
• Advanced airway management
• Artificial ventilation

The OOH-DNR does not prevent emergency comfort care, pain management, or supplemental oxygen. It applies specifically to resuscitation interventions.

Where the OOH-DNR Applies

The order is valid in any out-of-hospital setting:

• Private homes and apartments
• Nursing homes and assisted living facilities
• Clinics and outpatient facilities
• Public spaces (restaurants, parks, churches)
• Emergency rooms (before formal hospital admission)

Once you're formally admitted as an inpatient, the in-hospital DNR system takes over.

The Double-Signature Requirement

Texas is unusually strict about OOH-DNR execution. The applicable signing pathway depends on the patient:

1. The patient or authorized declarant — the patient, legal guardian, MPOA agent or proxy, or qualified relative, as applicable
2. The physician(s) — the attending physician, or two physicians under the no-relative pathway
3. Two qualified witnesses or a notary public — when required; Section F does not require witnesses or a notary

But here's where Texas adds an extra layer: the form includes a second signature block at the bottom where all parties sign again to acknowledge that the document has been fully completed. This "double-signing" requirement catches many people off guard — missing the second signature can render the entire form invalid.

Formatting Rules That Matter

The OOH-DNR has specific physical format requirements:

• Paper size: Standard 8.5" x 11"
• Layout: Use the clinical order on the front and instructions on the back; separate sheets may still be honored if the form is fully completed

Use the standard format to reduce confusion, although DSHS guidance says EMS may honor a properly executed form even if the instructions are not on the opposite side.

OOH-DNR Identification Devices

Texas law recognizes two alternatives to carrying the physical paper form:

• Yellow plastic bracelet featuring the word "Texas" and "Do Not Resuscitate"
• Metal bracelet or necklace with the words "Texas Do Not Resuscitate--OOH" (the abbreviation is part of the official standard)

These devices must be purchased from state-approved manufacturers. EMS personnel must honor a valid identification device in the same way they would honor the signed paper form.

Who Can Request an OOH-DNR

The form has several pathways for someone acting for a patient who lacks capacity:

• The patient's legal guardian
• A designated agent under a Medical Power of Attorney
• A qualified relative under the statutory hierarchy (spouse, then adult children, with the active child required to secure a waiver or consent from the other reasonably available adult children, then parents, then nearest relative)
• The attending physician when acting under the form's prior-directive or nonwritten-directive pathway
• Two physicians when no guardian, agent, proxy, or qualified relative is available

The attending physician must document the order in the medical record and sign the physician statement required by the applicable pathway.

Revoking the OOH-DNR

Like all Texas advance directives, the OOH-DNR can be revoked at any time, regardless of the patient's mental capacity:

• Verbal instruction to a physician or EMS provider
• Physical destruction of the form
• Removal of the identification bracelet or necklace
• Executing a new form that contradicts the prior one

The Texas Advance Directive & Living Will Kit includes the OOH-DNR form with step-by-step formatting guidance and the double-signature walkthrough that prevents the most common execution errors.

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