Article Map
Preview - Do Not Resuscitate Order Form
Do Not Resuscitate Order (DNR) - [State Name]
This Do Not Resuscitate Order (DNR) is made in accordance with the laws of [State Name]. It expresses the individual's wishes regarding resuscitation efforts in the event of cardiac arrest or respiratory failure.
By signing this document, I, [Full Name], residing at [Address], hereby declare my wishes regarding resuscitation efforts, as follows:
- I do not wish to receive cardiopulmonary resuscitation (CPR) or advanced cardiac life support (ACLS) in the event of cardiac arrest.
- I understand that this order may affect my medical care and that it is my responsibility to inform my healthcare providers of my decision.
Please provide the following information at the time of execution of this DNR:
- Patient Name: _____________________________
- Date of Birth: _____________________________
- Healthcare Provider Name: _____________________________
- Healthcare Provider Contact Information: _____________________________
Signatures:
Patient Signature: _____________________________ Date: ___________
Witness Signature: _____________________________ Date: ___________
This order shall remain in effect until revoked. I understand my rights to modify or cancel this DNR Order at any time, and that a copy of this document is as valid as the original.
It is advisable to keep a copy of this order in a location where it can be easily accessed in case of a medical emergency.
Do Not Resuscitate Order - Adapted for Each State
Popular Documents
Consolation Bracket - Enjoy the camaraderie and sportsmanship on display.
For anyone considering estate planning, learning about the benefits of a unique property transfer method can be invaluable; you may want to explore the modern approach to a Lady Bird Deed, which offers flexibility in managing real estate while ensuring a smoother transition of ownership.
Advance Beneficiary Notice of Noncoverage - Providers can use this form to protect themselves from non-payment claims by Medicare.
Similar forms
- Living Will: This document outlines your wishes regarding medical treatment in situations where you cannot communicate. Like a DNR, it ensures your preferences are respected during serious health crises.
- Healthcare Proxy: A healthcare proxy designates someone to make medical decisions on your behalf if you are unable to do so. Similar to a DNR, it empowers someone to act according to your wishes.
- Advance Directive: An advance directive combines elements of a living will and healthcare proxy. It allows you to specify your treatment preferences and appoint someone to make decisions for you, ensuring your choices are honored.
- POLST (Physician Orders for Life-Sustaining Treatment): This document translates your treatment preferences into actionable medical orders. Like a DNR, it is often used in emergency situations to guide healthcare providers.
- Motorcycle Bill of Sale: To facilitate a secure transaction, it's vital to complete a motorcycle bill of sale, which legally documents the transfer of ownership. For more information, you can refer to Auto Bill of Sale Forms.
- Do Not Intubate Order: This order specifically instructs medical personnel not to insert a breathing tube. Similar to a DNR, it reflects your wishes regarding life-sustaining treatments in critical situations.