Free Do Not Resuscitate Order Form for California
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Preview - California Do Not Resuscitate Order Form
California Do Not Resuscitate Order (DNR)
This Do Not Resuscitate Order (DNR) is created in accordance with California Health and Safety Code Sections 7180-7183. It expresses the wishes of the individual regarding resuscitation efforts in the event of cardiac arrest or respiratory failure.
Please fill out the information below:
- Patient Name: ___________________________________
- Date of Birth: ___________________________________
- Primary Physician: ___________________________________
- Physician's Contact Number: ______________________
- Emergency Contact Name: __________________________
- Emergency Contact Number: ______________________
The patient, named above, requests that in the event of a medical emergency resulting in cardiac arrest or respiratory failure, no efforts be made to revive or resuscitate them. This request is based on the patient’s stated values and medical conditions.
This order is valid and in effect until:
- Effective Date: ___________________________________
- Expiration Date (if any): ________________________
Signature of Patient or Legal Representative: _____________________
Date: ______________________________________________________
Signature of Witness: ________________________________________
Date: ______________________________________________________
This DNR may be revoked at any time by verbally stating the desire to revoke.
Please keep copies of this document in accessible locations and provide a copy to your primary physician.
Create Other Common Do Not Resuscitate Order Forms for Different States
Is a Dnr an Advance Directive - Clarity in the DNR's language is vital to avoid confusion during emergencies.
For further information on how to access the Sample Tax Return Transcript form, you can visit the following link: https://pdftemplates.info/sample-tax-return-transcript-form, which provides useful resources and guidance for obtaining this essential document.
Can a Medical Power of Attorney Override a Dnr - A significant way to ensure that patient preferences are acknowledged by healthcare providers.
Similar forms
A Do Not Resuscitate (DNR) Order is an important document that expresses a person's wishes regarding resuscitation efforts in the event of a medical emergency. Several other documents share similarities with a DNR, as they also address healthcare preferences and end-of-life decisions. Here’s a list of eight documents that are comparable to a DNR Order:
- Advance Healthcare Directive: This document allows individuals to outline their healthcare preferences, including decisions about life-sustaining treatments and appointing a healthcare proxy.
- Living Will: A living will specifies the types of medical treatment a person wishes to receive or avoid in situations where they cannot communicate their wishes.
- Healthcare Power of Attorney: This legal document designates someone to make healthcare decisions on behalf of an individual if they are unable to do so themselves.
- Physician Orders for Life-Sustaining Treatment (POLST): POLST is a medical order that translates a patient’s wishes regarding life-sustaining treatments into actionable medical orders for healthcare providers.
- Do Not Intubate (DNI) Order: Similar to a DNR, a DNI specifically instructs healthcare providers not to perform intubation, which is the placement of a tube to assist with breathing.
- Five Wishes Document: This document combines a living will with a healthcare power of attorney and addresses personal, emotional, and spiritual wishes for end-of-life care.
- Emergency Medical Services (EMS) Do Not Resuscitate Order: This form is used specifically by EMS personnel to honor a patient's DNR wishes in emergency situations outside of a hospital setting.
- Florida ATV Bill of Sale Form: For those buying or selling all-terrain vehicles, the detailed ATV Bill of Sale document ensures that all necessary information about the transaction is clearly outlined.
- Comfort Care Order: This order focuses on providing comfort measures rather than aggressive treatment, allowing for a peaceful end-of-life experience.
Understanding these documents can help individuals make informed decisions about their healthcare and ensure their wishes are respected. It is essential to discuss these preferences with loved ones and healthcare providers to avoid confusion during critical moments.