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Preview - Illinois Do Not Resuscitate Order Form

Illinois Do Not Resuscitate Order

This document serves as a legally binding Do Not Resuscitate (DNR) order in accordance with Illinois law. It allows the signer to indicate their wishes concerning resuscitative measures in the event of a medical emergency.

Patient Information:

  • Patient Name: ______________________
  • Date of Birth: ______________________
  • Address: ____________________________
  • City, State, Zip: ___________________

Authorized Person:

  • Name: ______________________________
  • Relationship to Patient: ______________
  • Contact Number: ______________________

This order states that the patient does not wish to receive cardiopulmonary resuscitation (CPR) or other life-sustaining measures in the event of cardiac or respiratory arrest. The effectiveness of this order is contingent upon clear communication to medical personnel.

Signature:

  • Patient's Signature: ___________________
  • Date: ________________________________

If signed by a representative, please fill out the following:

  • Representative's Signature: ____________
  • Relationship to Patient: ______________
  • Date: ________________________________

This DNR order will be honored by emergency medical services in Illinois. It is recommended to keep a copy of this order in an accessible location and inform family members and healthcare providers about its existence.

⇓ Do Not Resuscitate Order PDF

Create Other Common Do Not Resuscitate Order Forms for Different States

Is a Dnr an Advance Directive - A DNR does not prevent comfort measures like pain relief from being provided.

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Dnr Paperwork - This document is a way for patients to take charge of their healthcare journey.

Similar forms

  • Advance Directive: This document outlines a person's preferences for medical treatment in situations where they may be unable to communicate. Like a DNR, it guides healthcare providers in making decisions aligned with the patient's wishes.
  • Living Will: A living will specifies what types of medical treatment a person does or does not want if they become terminally ill or incapacitated. It serves a similar purpose to a DNR by expressing the individual's desires regarding end-of-life care.
  • Power of Attorney for Healthcare: This document designates someone to make healthcare decisions on behalf of an individual if they are unable to do so. It complements a DNR by ensuring that someone trusted can advocate for the patient's wishes.
  • Physician Orders for Life-Sustaining Treatment (POLST): POLST forms provide specific medical orders based on a patient's preferences regarding life-sustaining treatments. Like a DNR, it is intended for patients with serious illnesses and is honored by healthcare providers.
  • Trailer Bill of Sale: This essential document facilitates the transfer of ownership of a trailer in Louisiana and ensures legal recognition of the transaction. For comprehensive details and to complete your transaction, refer to the Motor Vehicle Bill of Sale.
  • Do Not Intubate Order: This order specifically instructs medical personnel not to insert a breathing tube in the event of respiratory failure. It is similar to a DNR as both documents focus on limiting aggressive medical interventions.
  • Comfort Care Order: This document emphasizes the provision of comfort measures rather than curative treatments. It aligns with the principles of a DNR by prioritizing quality of life over aggressive medical interventions.
  • Healthcare Proxy: A healthcare proxy allows an individual to appoint someone to make medical decisions on their behalf. This document can work alongside a DNR to ensure that the appointed person understands and respects the patient's wishes.
  • End-of-Life Care Plan: This comprehensive plan outlines a person's preferences for care as they approach the end of life. It may include elements of a DNR, ensuring that all aspects of care align with the patient's values and desires.