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. 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. Three parties must sign:

1. The patient (or an authorized surrogate if the patient lacks capacity)
2. The attending physician
3. Two qualified witnesses or a notary public

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: Must be double-sided — clinical order on the front, detailed instructions on the back
• Single-page: Although EMS can honor a form printed on two separate sheets, maintaining the double-sided format avoids complications during inspections

These aren't optional formatting preferences. Texas EMS training includes recognition of the specific physical layout, and a non-standard format can cause delays when seconds matter.

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 Resuscitat–OOH" (the abbreviation is part of the official standard)

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

Who Can Request an OOH-DNR

Only specific individuals can sign on behalf of a patient who lacks capacity:

• The patient's legal guardian
• A designated agent under a Medical Power of Attorney
• A qualified surrogate under the statutory hierarchy (spouse, then adult children with consensus, then parents, then nearest relative)

The attending physician must also agree that the OOH-DNR is medically appropriate.

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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