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Pennsylvania Do Not Resuscitate (DNR) Order Template

This Do Not Resuscitate (DNR) Order is created pursuant to Pennsylvania laws governing advance directives and medical treatment decisions. It expresses the wishes of the individual regarding resuscitative measures.

Patient Information:

  • Full Name: ___________________________
  • Date of Birth: ________________________
  • Address: ______________________________

Physician Information:

  • Physician's Name: ______________________
  • License Number: ______________________
  • Contact Information: ___________________

Decision Statement:

I, the undersigned, hereby state that I do not wish to receive cardiopulmonary resuscitation (CPR) or other life-sustaining treatment in the event of cardiac or respiratory arrest.

Additional Instructions (if any):

___________________________________________________________

By signing this document, I acknowledge that I understand the implications of my decision and have discussed it with my physician.

Signature of Patient or Legal Representative: ____________________

Date: ____________________

Witness Information:

  • Witness Name: ______________________
  • Signature: __________________________
  • Date: ______________________________

This DNR Order is valid until revoked or until the patient's wishes change.

⇓ Do Not Resuscitate Order PDF

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Similar forms

A Do Not Resuscitate (DNR) Order form is a specific medical document that indicates a person's wishes regarding resuscitation efforts in the event of a medical emergency. Several other documents serve similar purposes in expressing healthcare preferences. Here are six such documents:

  • Living Will: A living will outlines a person's preferences for medical treatment in situations where they may not be able to communicate their wishes. It typically addresses end-of-life care and specific medical interventions.
  • Bill of Sale: This legal document is vital for accurately transferring ownership of personal property. For more information about the Pennsylvania Bill of Sale form, visit pdftemplates.info/pennsylvania-bill-of-sale-form/.
  • Healthcare Proxy: This document allows an individual to appoint someone to make medical decisions on their behalf if they become incapacitated. The appointed person, known as an agent, is responsible for ensuring that the individual's healthcare preferences are followed.
  • Advance Healthcare Directive: An advance healthcare directive combines elements of a living will and a healthcare proxy. It provides instructions for medical care and designates a person to make decisions if the individual is unable to do so.
  • Physician Orders for Life-Sustaining Treatment (POLST): A POLST form is a medical order that specifies a patient’s preferences for treatments, including resuscitation. It is designed for individuals with serious health conditions and is signed by a physician.
  • Do Not Intubate (DNI) Order: A DNI order is similar to a DNR but specifically indicates that a patient does not wish to be intubated. This is relevant in situations where breathing assistance is needed but resuscitation is not desired.
  • Medical Power of Attorney: A medical power of attorney designates an individual to make healthcare decisions on behalf of someone else. This document is activated when the person is unable to make their own decisions due to illness or injury.

Each of these documents plays a crucial role in ensuring that a person's healthcare preferences are respected and followed, particularly in critical situations.