Forms and Templates

Forms and Templates
Homepage ➨ Attorney-Approved Do Not Resuscitate Order Document
Content Overview

Guide to Writing Do Not Resuscitate Order

Filling out a Do Not Resuscitate (DNR) Order form is an important step in ensuring that your healthcare preferences are respected. It allows individuals to communicate their wishes regarding resuscitation efforts in the event of a medical emergency. Below are the steps to complete the form effectively.

  1. Obtain the Do Not Resuscitate Order form from your healthcare provider or download it from a reliable source.
  2. Read the instructions carefully to understand the requirements for your state or facility.
  3. Fill in your personal information, including your full name, date of birth, and any other identifying details required.
  4. Indicate your decision regarding resuscitation by checking the appropriate box or writing your preference clearly.
  5. Sign and date the form to validate your decision. If you are unable to sign, a designated representative may do so on your behalf.
  6. Have a witness sign the form, if required by your state’s regulations. This could be a family member, friend, or healthcare professional.
  7. Make copies of the completed form for your records and share them with your healthcare provider, family members, and anyone involved in your care.
  8. Keep the original form in a safe, accessible location where it can be easily found in case of an emergency.

Do Not Resuscitate OrderDocuments for Specific US States

PDF Form Specs

Fact Name Description
Definition A Do Not Resuscitate (DNR) Order is a legal document that instructs medical personnel not to perform cardiopulmonary resuscitation (CPR) if a person's heart stops beating or if they stop breathing.
State-Specific Forms Each state has its own version of the DNR form, governed by specific laws. For example, in California, the DNR is regulated under the California Health and Safety Code § 7180.
Eligibility Typically, DNR orders are intended for individuals with terminal illnesses or those who have a poor prognosis. It's crucial to have a discussion with a healthcare provider before completing the form.
Revocation A DNR order can be revoked at any time by the individual or their legal representative. This can be done verbally or by destroying the document.

FAQ

What is a Do Not Resuscitate (DNR) Order?

A Do Not Resuscitate Order (DNR) is a medical order that instructs healthcare providers not to perform cardiopulmonary resuscitation (CPR) if a patient's heart stops beating or if they stop breathing. This order is typically used by individuals with serious health conditions who wish to avoid aggressive life-saving measures in the event of a medical emergency.

Who can request a DNR Order?

A DNR order can be requested by a patient who is capable of making their own medical decisions. If the patient is unable to communicate their wishes, a legally authorized representative, such as a family member or healthcare proxy, may make the request on their behalf. It is essential that the decision reflects the patient's values and preferences.

How is a DNR Order created?

To create a DNR order, the following steps are generally taken:

  1. The patient or authorized representative discusses their wishes with a healthcare provider.
  2. The healthcare provider evaluates the patient's medical condition and prognosis.
  3. If appropriate, the provider completes the DNR order form, which may vary by state.
  4. The completed form is signed by the patient or their representative and the healthcare provider.

It is important to keep copies of the DNR order in accessible locations, such as with the patient’s medical records and at home.

Will a DNR Order affect other medical treatments?

No, a DNR order specifically pertains to resuscitation efforts. It does not prevent healthcare providers from administering other types of medical care or treatments. Patients can still receive medications, nutrition, and comfort care, even if they have a DNR order in place.

Can a DNR Order be revoked?

Yes, a DNR order can be revoked at any time by the patient or their authorized representative. To revoke the order, the patient should communicate their decision to their healthcare provider and ensure that the DNR order is removed from their medical records. It is also advisable to inform family members and caregivers of the change.

Where should a DNR Order be kept?

A DNR order should be kept in a place that is easily accessible to healthcare providers. Recommended locations include:

  • In the patient's medical records.
  • At home, on the refrigerator or in a visible location.
  • With the patient when they are in a healthcare facility or traveling.

Ensuring that the DNR order is readily available can help prevent confusion during a medical emergency.

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Do Not Resuscitate Order Example

Do Not Resuscitate Order Template

This Do Not Resuscitate (DNR) Order is made in accordance with the laws of [State Name]. Please complete the following information to ensure your wishes are accurately documented.

Patient Information:

  • Patient Full Name: ___________________________
  • Date of Birth: ___________________________
  • Address: ___________________________
  • City, State, ZIP: ___________________________

Healthcare Proxy Information:

  • Full Name of Healthcare Proxy: ___________________________
  • Relationship to Patient: ___________________________
  • Contact Number: ___________________________

Order Details:

This order indicates that the patient has chosen not to receive cardiopulmonary resuscitation (CPR) in the event of cardiac arrest.

The patient understands that:

  1. This DNR order will be respected by medical personnel.
  2. Other medical interventions may still be administered as deemed appropriate.
  3. This order should be placed in the patient’s medical record and made available to emergency medical services.

Patient Signature: ___________________________

Date: ___________________________

Witness Information:

  • Witness Full Name: ___________________________
  • Signature: ___________________________
  • Date: ___________________________

This document serves as a critical communication tool regarding the patient's end-of-life wishes. Please ensure that copies are provided to the healthcare proxy and kept in accessible locations.