Pennsylvania Do Not Resuscitate (DNR) Form

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Pennsylvania Do Not Resuscitate (DNR) Form

A Pennsylvania do not resuscitate form is a medical order that states whether CPR should be performed if a patient is in cardiac or respiratory arrest. Pennsylvania provides a DNR order in its POLST form, which also includes medical treatment preferences for certain end-of-life care. A POLST form must be executed by a health care professional.

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Last updated July 22nd, 2025

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A Pennsylvania do not resuscitate form is a medical order that states whether CPR should be performed if a patient is in cardiac or respiratory arrest. Pennsylvania provides a DNR order in its POLST form, which also includes medical treatment preferences for certain end-of-life care. A POLST form must be executed by a health care professional.

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Signing Requirements

The patient and the issuing health care practitioner must sign the DNR.[1] The patient’s health care surrogate or other legally authorized representative may sign on their behalf.

Out-of-Hospital Do-Not-Resuscitate Order

The Pennsylvania Out-of-Hospital Do-Not-Resuscitate Order is a simple form that provides instructions to forgo cardiopulmonary resuscitation if the patient’s heart or breathing stops.

This form is not available online and must be ordered by a medical professional.

Do Not Resuscitate (Preview)

Sources

  1. § 5484(b)