Content Overview
Guide to Writing Pennsylvania Do Not Resuscitate Order
Completing the Pennsylvania Do Not Resuscitate Order form is a crucial step in ensuring that your healthcare preferences are respected. Once you have the form filled out, it should be shared with your healthcare provider and kept in a place where it can be easily accessed in case of a medical emergency.
- Obtain the Pennsylvania Do Not Resuscitate Order form. You can find it online or request it from your healthcare provider.
- Fill in your full name, date of birth, and address at the top of the form.
- Indicate whether you are completing this order voluntarily.
- Choose a healthcare provider to sign the form. This can be your doctor or another licensed healthcare professional.
- Have the healthcare provider sign and date the form. Their signature confirms that they understand your wishes.
- Provide space for a witness signature. This should be someone who is not related to you and is at least 18 years old.
- Sign and date the form yourself to affirm your decision.
- Make copies of the completed form. Keep one for your records and give copies to your healthcare provider and family members.
PDF Form Specs
| Fact Name | Details |
|---|---|
| Definition | The Pennsylvania Do Not Resuscitate Order (DNR) form is a legal document that allows individuals to refuse resuscitation in the event of cardiac or respiratory arrest. |
| Governing Law | This form is governed by the Pennsylvania Consolidated Statutes, Title 20, Chapter 54, also known as the Health Care Decisions Act. |
| Eligibility | Any adult individual who is capable of making health care decisions can complete a DNR order. |
| Signature Requirement | The DNR order must be signed by the individual or their authorized representative, and it must be witnessed by two adults. |
| Healthcare Provider's Role | Healthcare providers must comply with the DNR order once it is properly executed and presented. |
| Revocation | The individual can revoke the DNR order at any time, verbally or in writing, and must communicate this decision to their healthcare provider. |
FAQ
What is a Pennsylvania Do Not Resuscitate Order (DNR) form?
A Pennsylvania Do Not Resuscitate Order (DNR) form is a legal document that allows individuals to express their wishes regarding resuscitation efforts in the event of a medical emergency. This form indicates that the person does not want cardiopulmonary resuscitation (CPR) or other life-saving measures to be performed if their heart stops beating or they stop breathing. It is crucial for ensuring that medical professionals respect the individual's preferences in critical situations.
Who can complete a DNR form in Pennsylvania?
In Pennsylvania, any adult who is capable of making their own medical decisions can complete a DNR form. This includes individuals who are at least 18 years old and are of sound mind. If a person is unable to complete the form due to a medical condition, a legally authorized representative, such as a family member or legal guardian, may sign the form on their behalf. It is essential that the individual’s wishes are clearly communicated and documented.
How do I obtain a DNR form in Pennsylvania?
Obtaining a DNR form in Pennsylvania is a straightforward process. You can acquire the form through various means:
- Visit the Pennsylvania Department of Health website, where the DNR form is available for download.
- Request a copy from your healthcare provider or hospital.
- Contact local health organizations or legal aid offices that may provide the form and assistance in completing it.
Once you have the form, ensure that it is filled out correctly and signed by both the individual and their physician.
What should I do after completing the DNR form?
After completing the DNR form, it is important to take several steps to ensure that your wishes are respected:
- Share copies of the signed DNR form with your healthcare providers, family members, and any other individuals involved in your care.
- Keep a copy of the form in an easily accessible location, such as your home or with your medical records.
- Consider discussing your decision with your healthcare team to ensure they understand your preferences and can provide appropriate care.
By taking these steps, you help ensure that your wishes regarding resuscitation are honored during a medical emergency.
Can I change or revoke my DNR order?
Yes, you can change or revoke your DNR order at any time as long as you are capable of making your own medical decisions. To revoke a DNR order, you can simply destroy the existing form and inform your healthcare providers of your decision. If you choose to create a new DNR form, make sure it is properly signed and shared with relevant parties. Keeping your medical team informed of any changes is essential to ensure your current wishes are respected.
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Pennsylvania Do Not Resuscitate Order Example
Pennsylvania Do Not Resuscitate Order (DNR)
This Do Not Resuscitate Order (DNR) is designed for use in the state of Pennsylvania, following relevant state laws regarding advance directives and medical treatment preferences.
Patient Information:
- Patient Name: _______________________________
- Date of Birth: _____________________________
- Address: ___________________________________
- City, State, Zip: ___________________________
- Patient's Healthcare Provider: ________________
- Provider's Contact Information: _______________
Order Declaration:
The individual named above has decisively chosen to forgo cardiopulmonary resuscitation (CPR) should their heart stop or they stop breathing. This decision is made voluntarily and without coercion. The order is valid as long as the patient remains of sound mind and has the capacity to make medical decisions.
Additional Instructions:
- Specify any additional wishes regarding medical care: _____________________________________________________
- This order applies in all health care settings unless stated otherwise: ______________________________________
Signatures:
Patient or Legal Representative Signature: ___________________________ Date: ___________
If signed by a legal representative, please include:
- Representative's Name: ___________________________________
- Relationship to Patient: _________________________________
Witness Signatures:
- Witness 1 Name: ___________________________________ Signature: ______________________
- Witness 2 Name: ___________________________________ Signature: ______________________
This document serves as a formal expression of the patient's wishes regarding resuscitation efforts. Please ensure that copies are available to relevant healthcare providers and family members.