DNR in the Netherlands: penning, document, tattoo
If your heart stops in a Dutch street, an ambulance crew will start resuscitation within seconds. They are trained to act on the assumption that you want to be revived, unless they can see, immediately, that you do not. That last word — see — is what makes the difference between a wish and an instruction the ambulance can follow.
This explainer covers the three ways that a do-not-resuscitate decision is made visible in the Netherlands: the niet-reanimerenpenning (medallion), the written wilsverklaring, and the tattoo. What is legally binding, where to obtain each, and when the ambulance respects it.
What "DNR" means here
In Dutch healthcare, a niet-reanimeren-besluit (do-not-resuscitate decision) is a request not to be resuscitated in the event of cardiac or respiratory arrest. It is not a decision to refuse other care. It does not mean palliative or comfort treatments will be withheld. It applies to one specific intervention — cardiopulmonary resuscitation (CPR) — at one specific moment.
The decision can be made by the patient (in advance or in the moment, if able) or, in some clinical situations, by the treating doctor on medical grounds. This explainer covers the patient-driven version: how a healthy or chronically ill person makes their own DNR wish operationally enforceable in the Netherlands.
The penning: the most reliable instruction in an emergency
The niet-reanimerenpenning is a small metal medallion worn on a chain around the neck. Its purpose is single and practical: to be visible the moment a paramedic opens your shirt to start CPR.
The penning carries the wearer's name, date of birth, signature, photo and the explicit text "Ik wil niet gereanimeerd worden" (I do not wish to be resuscitated). Since 2 January 2025, the penning is issued by the NVVE (Nederlandse Vereniging voor een Vrijwillig Levenseinde). It was previously distributed by the Patiëntenfederatie Nederland, which stopped issuing it in 2024 after the government ended the subsidy. To obtain one, the applicant must be at least 18, fill in an application form, sign it in the presence of two witnesses, and supply a passport photo. The cost is €55 for non-members and €40 for NVVE members.
In the standard Dutch ambulance protocol, a clearly visible niet-reanimerenpenning is treated as a binding refusal of CPR. The ambulance crew checks the photo against the patient's face and, if there is no doubt, withholds resuscitation. There is no need for relatives to be present or to confirm the wish.
The penning has limits. It must be visible — under clothing, jewellery or a coat, it may not be seen in time. It only refuses CPR; for broader treatment refusals, a separate document is needed. And if there is genuine doubt about identity, the crew may begin resuscitation while it is resolved.
The wilsverklaring: the document behind the wish
A behandelverbod (treatment refusal) within a wilsverklaring (advance directive) is the written form of the same wish, often broader. It can refuse not only CPR but also, for example, mechanical ventilation, tube feeding, or further hospitalisation in defined circumstances. Templates are published by the NVVE and can be drafted with the help of the huisarts (general practitioner) or a notaris (notary).
For the document to function in practice, two things matter: it must be discussed with the huisarts and recorded in the patient's medical file, and the family — particularly the gevolmachtigde (designated representative) — must know where it is kept. A wilsverklaring in a drawer that no one can find at the moment of need is, operationally, no instruction at all.
In the home setting, where the huisarts knows the patient, a written behandelverbod is generally honoured. In an out-of-home emergency where the ambulance crew has no time to read papers, the document on its own is less reliable than the penning. The two are complementary: the penning for the seconds, the wilsverklaring for the longer decisions that follow.
The tattoo: visible, contested, not legally binding
In recent years, "DO NOT RESUSCITATE" tattoos have become a topic of public discussion in the Netherlands and elsewhere. They are visible, permanent, and require nothing to be carried.
In the Dutch context, the tattoo on its own is not recognised as a legally binding instruction. It does not carry a verifiable signature, a witness, or proof that the wish remains current. Ambulance protocols do not list it as grounds to withhold CPR. A tattoo may prompt the crew to look for a penning or a written document, but on its own it does not decide the question.
This is not a Dutch peculiarity. The international consensus among emergency medicine bodies is similar: tattoos express intent; they do not establish a current, verifiable refusal of treatment.
Children and minors
A niet-reanimerenpenning is issued to people aged 18 and over. For children, decisions about resuscitation are made by parents or guardians together with the treating doctor, recorded in the medical file, and discussed with the school, hospice or care setting where relevant. There is no equivalent self-issued penning for minors.
When the ambulance respects which
In short:
- Penning, clearly visible, photo matches, no doubt: the ambulance withholds CPR.
- Wilsverklaring with behandelverbod, in the medical file, known to the huisarts: respected at home and in planned care; less reliable in an unannounced emergency.
- Tattoo: not, on its own, an instruction the ambulance follows.
For maximum reliability, the recommendation from the NVVE is a combination: a penning on the body for emergencies, a wilsverklaring on file for the rest of care, and a conversation with the huisarts that ties the two together.
In the app
In the Personal Portal you record whether you carry a niet-reanimerenpenning, the date your wilsverklaring was discussed with your huisarts, and the location of the original document. The information is visible to the gevolmachtigde you choose, so the right person can answer when asked.
Closed beta — access by invitation.
Sources
- NVVE — Nederlandse Vereniging voor een Vrijwillig Levenseinde, issuer of the niet-reanimerenpenning since 2 January 2025; wilsverklaring templates and guidance on behandelverbod. https://www.nvve.nl
- KNMG — Royal Dutch Medical Association, professional guidance on niet-reanimerenbesluiten. https://www.knmg.nl
- Patiëntenfederatie Nederland — historical issuer of the niet-reanimerenpenning until 2024. https://www.patientenfederatie.nl