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Homepage ➨ Attorney-Approved Do Not Resuscitate Order Document ➨ Printable Do Not Resuscitate Order Form for the State of California
Content Overview

Guide to Writing California Do Not Resuscitate Order

Filling out the California Do Not Resuscitate Order form is an important step for ensuring your healthcare preferences are respected. This process requires careful attention to detail. Follow these steps to complete the form accurately.

  1. Obtain a copy of the California Do Not Resuscitate Order form. You can find it online or request it from your healthcare provider.
  2. Fill in your full name, date of birth, and address at the top of the form.
  3. Indicate your wishes regarding resuscitation by checking the appropriate box. Make sure to read the options carefully.
  4. Sign and date the form. Your signature is essential for the document to be valid.
  5. Have your physician sign the form. This step is crucial as it validates your request.
  6. Make copies of the completed form for your records and for your healthcare providers.
  7. Keep the original form in a safe but accessible place. Inform your family and caregivers where it can be found.

PDF Form Specs

Fact Name Description
Purpose The California Do Not Resuscitate (DNR) Order form allows individuals to express their wish not to receive cardiopulmonary resuscitation (CPR) in the event of a cardiac arrest.
Governing Law The California DNR Order is governed by California Health and Safety Code Section 7190-7199.
Eligibility Any adult capable of making medical decisions can complete a DNR Order. Minors require consent from a parent or legal guardian.
Form Availability The DNR Order form is available online and at healthcare facilities across California.
Signature Requirement The form must be signed by the individual or their authorized representative, along with a physician's signature to be valid.
Revocation Individuals can revoke their DNR Order at any time. This can be done verbally or by destroying the form.
Emergency Medical Services Emergency medical personnel are required to honor a valid DNR Order when it is presented at the scene of a medical emergency.
Additional Instructions The DNR Order form can include additional instructions regarding other medical treatments, allowing for personalized care preferences.

FAQ

What is a California Do Not Resuscitate Order (DNR) form?

A California Do Not Resuscitate Order (DNR) form is a legal document that allows a person to express their wishes regarding resuscitation efforts in the event of a medical emergency. Specifically, it instructs healthcare providers not to perform cardiopulmonary resuscitation (CPR) if the individual stops breathing or their heart stops beating. This form is particularly important for individuals with terminal illnesses or those who wish to avoid aggressive medical interventions at the end of life.

Who can complete a DNR form in California?

In California, any adult who is capable of making their own healthcare decisions can complete a DNR form. This includes individuals who are 18 years or older and are of sound mind. Additionally, a parent or legal guardian may complete a DNR form for a minor. It is important that the individual understands the implications of the DNR order and discusses their wishes with family members and healthcare providers.

How do I obtain a DNR form in California?

To obtain a DNR form in California, individuals can request one from their healthcare provider or download it from the California Department of Public Health website. The form is typically available in both English and Spanish. After completing the form, it must be signed by the individual and their physician to be valid. It is advisable to keep copies of the signed DNR form in accessible locations and share them with family members and healthcare providers.

What should I do with the completed DNR form?

Once the DNR form is completed and signed, it is essential to ensure that it is readily available in case of a medical emergency. Here are some steps to consider:

  1. Keep a copy of the DNR form in a visible place at home, such as on the refrigerator or near the bedside.
  2. Provide copies to your healthcare providers, including your primary care physician and any specialists.
  3. Share the document with family members and close friends to ensure they understand your wishes.
  4. Consider carrying a wallet-sized card that indicates you have a DNR order in place.

Can I change or revoke my DNR order?

Yes, individuals have the right to change or revoke their DNR order at any time. If you wish to revoke the order, you can do so verbally or in writing. It is important to inform your healthcare providers and family members about the change. To create a new DNR order, you will need to complete a new form and ensure it is signed by your physician. Keeping everyone informed about your current wishes is vital for ensuring your preferences are respected.

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California Do Not Resuscitate Order Example

California Do Not Resuscitate Order (DNR)

This Do Not Resuscitate Order (DNR) is established in accordance with California Health and Safety Code Section 4970-4979. It reflects the wishes of the individual regarding resuscitation in the event of cardiac or respiratory arrest.

Please fill in the information below:

  • Patient's Name: ________________________________
  • Date of Birth: ________________________________
  • Address: _____________________________________
  • City: _____________________
  • State: California
  • Zip Code: ____________________

The patient hereby requests that, in the event of cardiac or respiratory arrest, no resuscitation measures, including but not limited to chest compressions, intubation, or defibrillation, be undertaken.

This order is intended to be honored by all healthcare providers, including, but not limited to:

  • Hospitals
  • Nursing homes
  • Ambulance services

Signature of Patient: ____________________________________

Date: ____________________________________

If the patient is unable to sign, a legally authorized representative may sign, as indicated below:

Legal Representative's Name: _________________________

Relationship to Patient: _____________________________

Signature of Legal Representative: _____________________

Date: ____________________________________

This document should be kept in a prominent location and a copy should be provided to all healthcare providers involved in the patient's care.