Free Do Not Resuscitate Order Form for Ohio
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Preview - Ohio Do Not Resuscitate Order Form
Ohio Do Not Resuscitate Order Template
This Do Not Resuscitate (DNR) Order is created in accordance with Ohio state laws for individuals who wish to refuse resuscitation in the event of a medical emergency.
Patient Information:
- Patient Full Name: ________________________________
- Patient Date of Birth: _____________________________
- Patient Address: __________________________________
- Patient Phone Number: ____________________________
Physician Information:
- Physician Full Name: _____________________________
- Physician Phone Number: _________________________
- Physician License Number: ________________________
Patient Statement:
I, the undersigned, hereby declare that I do not want resuscitative measures used to prolong my life in the event of cardiac or respiratory arrest.
Signature: ______________________________________
Date: _________________________________________
This order is effective immediately upon signing and shall remain in effect until revoked by the patient.
Witness Statements:
Witness 1 Name: _____________________________________
Witness 1 Signature: _________________________________
Witness 1 Date: _____________________________________
Witness 2 Name: _____________________________________
Witness 2 Signature: _________________________________
Witness 2 Date: _____________________________________
Please keep a copy of this DNR Order in a prominent place and provide copies to your physician and family members.
Create Other Common Do Not Resuscitate Order Forms for Different States
Can a Medical Power of Attorney Override a Dnr - A directive that communicates the decision to prioritize comfort over prolonged medical treatment.
Is a Dnr an Advance Directive - This form can be a key element in ensuring dignified end-of-life care.
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Dnr Paperwork - This order ensures that medical staff respect the patient's wishes in emergencies.
Similar forms
- Living Will: A living will outlines a person's wishes regarding medical treatment in situations where they cannot communicate. Like a Do Not Resuscitate Order, it provides guidance to healthcare providers about the individual's preferences for end-of-life care.
- Healthcare Power of Attorney: This document designates someone to make medical decisions on behalf of an individual if they become incapacitated. Similar to a DNR, it ensures that a person's healthcare preferences are respected.
- Power of Attorney Form: This document allows an individual to designate someone to make important decisions on their behalf, ensuring their preferences are honored when they are not able to act. For more information, visit pdftemplates.info/power-of-attorney-form/.
- Advance Directive: An advance directive combines elements of both a living will and a healthcare power of attorney. It allows individuals to express their medical treatment preferences and appoint someone to make decisions for them, just like a DNR.
- Physician Orders for Life-Sustaining Treatment (POLST): A POLST form translates a patient’s wishes about resuscitation and other life-sustaining treatments into actionable medical orders. This is similar to a DNR in that it specifically addresses resuscitation efforts.
- Do Not Intubate (DNI) Order: A DNI order specifies that a patient should not be intubated if they cannot breathe on their own. Like a DNR, it focuses on limiting specific medical interventions in critical situations.
- Comfort Care or Palliative Care Orders: These orders focus on providing relief from pain and other distressing symptoms rather than curative treatment. They align with the philosophy of a DNR by prioritizing comfort over aggressive medical interventions.
- Organ Donation Consent: While not directly related to resuscitation, an organ donation consent form indicates a person's wishes regarding organ donation after death. Both documents reflect a person's values and decisions about their medical care and end-of-life choices.