Forms and Templates

Forms and Templates
Homepage ➨ Attorney-Approved Do Not Resuscitate Order Document ➨ Printable Do Not Resuscitate Order Form for the State of New York
Content Overview

Guide to Writing New York Do Not Resuscitate Order

Completing the New York Do Not Resuscitate Order form is an important step in ensuring that your healthcare preferences are respected. This document will need to be filled out carefully to reflect your wishes accurately. Below are the steps to guide you through the process.

  1. Obtain the New York Do Not Resuscitate Order form. You can find it online or request a copy from your healthcare provider.
  2. Fill in your full name, date of birth, and address at the top of the form.
  3. Indicate the name of your attending physician. This is the doctor who is primarily responsible for your care.
  4. Provide the date when the form is being completed.
  5. Sign the form in the designated area. Your signature confirms that you understand the contents of the document.
  6. Have your attending physician sign the form. This step is essential for the document to be valid.
  7. Make sure to date the physician's signature.
  8. Keep a copy of the completed form for your records.
  9. Provide copies of the form to your healthcare provider, family members, and anyone else involved in your care.

PDF Form Specs

Fact Name Description
Definition The New York Do Not Resuscitate (DNR) Order form allows patients to refuse resuscitation efforts in the event of cardiac or respiratory arrest.
Governing Law This form is governed by New York Public Health Law § 2994-a, which outlines the requirements for advance directives and DNR orders.
Eligibility Any adult who is capable of making their own medical decisions can complete a DNR order, ensuring their wishes are respected in critical situations.
Signature Requirement The DNR order must be signed by the patient or their legally authorized representative, along with a physician's signature to be valid.

FAQ

What is a Do Not Resuscitate (DNR) Order in New York?

A Do Not Resuscitate Order is a legal document that allows a person to refuse resuscitation efforts in the event of cardiac arrest or respiratory failure. In New York, this order is intended for individuals who wish to avoid life-saving measures, such as CPR, in situations where they are unable to communicate their wishes.

Who can request a DNR Order?

A DNR Order can be requested by any adult who is capable of making their own healthcare decisions. Additionally, a legally appointed healthcare proxy or a parent or guardian can request a DNR for a minor or an individual who is unable to make decisions due to incapacity.

How do I obtain a DNR Order in New York?

To obtain a DNR Order, follow these steps:

  1. Discuss your wishes with your healthcare provider. It's important to have a clear understanding of your health condition and treatment options.
  2. Your healthcare provider will complete the DNR form, which includes your name, date of birth, and signature, along with the signature of a physician.
  3. Make sure to keep copies of the signed DNR Order for your records and provide copies to your family and healthcare providers.

Is a DNR Order valid in all healthcare settings?

Yes, a properly executed DNR Order is valid across various healthcare settings in New York, including hospitals, nursing homes, and at home. However, it’s essential to ensure that healthcare providers are aware of your DNR status and have access to the documentation.

Can a DNR Order be revoked?

Absolutely. A DNR Order can be revoked at any time. To do so, simply inform your healthcare provider or family members of your decision. It’s advisable to destroy any copies of the DNR Order to prevent confusion.

What if I change my mind about a DNR Order?

If you change your mind about having a DNR Order, you can easily revoke it. Communicate your wishes clearly to your healthcare provider and family. It’s important to ensure that everyone involved in your care is aware of your updated preferences.

Are there any costs associated with obtaining a DNR Order?

Generally, there are no direct costs for obtaining a DNR Order itself, as it is a legal document provided by healthcare professionals. However, there may be associated costs for consultations with healthcare providers or for any necessary medical evaluations.

What should I do if I have questions about my DNR Order?

If you have questions or concerns regarding your DNR Order, reach out to your healthcare provider. They can provide guidance and clarification about the implications of the order and how it fits into your overall healthcare plan. Additionally, legal advisors specializing in healthcare law can offer assistance if needed.

Consider Popular Do Not Resuscitate Order Forms for Specific States

Out of Hospital Dnr - Healthcare facilities often have their own protocols regarding the implementation of DNR orders.

To facilitate the payment process, employers often rely on resources like the Blank Check Template, which helps streamline the creation of the Payroll Check form, ensuring all necessary details are accurately captured and completed in a timely manner.

Dnr Document - Individuals often complete a DNR as part of a broader conversation about their healthcare wishes.

Do Not Resuscitate Form Florida - Legally, DNR orders are recognized across various healthcare settings, including hospitals and nursing homes.

Pa Dnr Form - Acts as a strong assertion of the patient’s autonomy over their health care options.

New York Do Not Resuscitate Order Example

New York Do Not Resuscitate Order

This Do Not Resuscitate (DNR) Order is intended to express the wishes of the patient regarding medical treatment in accordance with New York state laws. This document should be placed in a prominent location within the patient’s medical records.

Patient Information:

  • Patient Name: ___________________________________
  • Date of Birth: ___________________________________
  • Address: ___________________________________
  • Phone Number: ___________________________________

Patient's Wishes:

I, the undersigned, wish to refuse all resuscitation efforts in the event of cardiac or respiratory arrest. This includes, but is not limited to, the following:

  • Cardiopulmonary resuscitation (CPR)
  • Intubation
  • Mechanical ventilation

Surrogate Decision Maker Information (if applicable):

  • Name: ___________________________________
  • Relationship to Patient: ___________________________
  • Contact Information: ____________________________

Signature:

I hereby declare that this Do Not Resuscitate Order accurately reflects my wishes.

Patient Signature: ________________________________

Date: _________________________________________

Witness Signature: _______________________________

Date: _________________________________________

This order will remain in effect until revoked in writing by the patient.