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Preview - North Carolina Do Not Resuscitate Order Form
North Carolina Do Not Resuscitate Order (DNR)
This Do Not Resuscitate Order (DNR) form is compliant with North Carolina state laws and is intended for individuals who wish to decline resuscitative measures in the event of cardiac arrest or respiratory failure.
Please fill out the information below:
- Patient's Name: ___________________________
- Date of Birth: ___________________________
- Address: ___________________________
- City: ___________________________
- State: North Carolina
- Zip Code: ___________________________
- Patient's Healthcare Provider Name: ___________________________
- Healthcare Provider Contact Number: ___________________________
The patient, named above, has decision-making capacity and understands the impact of this Do Not Resuscitate Order. The patient requests that in the event of a cardiac arrest or respiratory failure, no resuscitative measures, including but not limited to chest compressions, intubation, or defibrillation, be administered.
This order must be signed by the patient or the patient’s legally authorized representative:
- Signature of Patient or Authorized Representative: ___________________________
- Date: ___________________________
The designated healthcare provider is responsible for honoring this Do Not Resuscitate Order in all healthcare settings, including hospitals and emergency medical services.
This document should be kept in a prominent place and copies should be made available to all healthcare providers involved in the patient's care.
For more detailed information on DNR orders in North Carolina, consult Chapter 90, Article 3 of the North Carolina General Statutes.
Create Other Common Do Not Resuscitate Order Forms for Different States
Polst Form Illinois - A DNR may be accompanied by other advance directives for comprehensive planning.
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Do Not Resuscitate Form Georgia - A DNR does not affect the quality of care received prior to a cardiac event; only resuscitative efforts are declined.
Dnr Definition - A Do Not Resuscitate Order ensures that a person does not receive CPR or other life-saving measures in case of cardiac arrest.
Dnr Paperwork - This document may be revisited as personal health situations change.
Similar forms
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- Healthcare Power of Attorney: This document designates a person to make medical decisions on behalf of someone who is incapacitated. It complements a DNR by ensuring that the appointed individual understands the patient’s wishes regarding resuscitation.
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- Physician Orders for Life-Sustaining Treatment (POLST): POLST is a medical order that outlines a patient's preferences for treatments, including resuscitation. It is similar to a DNR in that it provides specific instructions for emergency medical personnel.
- Do Not Intubate Order: This order specifies that a patient should not be intubated in case of respiratory failure. It is similar to a DNR as both documents aim to limit aggressive medical interventions.
- Comfort Care Order: A comfort care order focuses on providing relief from pain and distress without prolonging life. Like a DNR, it emphasizes quality of life over aggressive treatment.
- Patient Preferences Document: This document records an individual's healthcare preferences and values. It serves as a guide for healthcare providers, similar to a DNR, by clarifying the patient's wishes regarding life-sustaining treatments.