Attorney-Approved Do Not Resuscitate Order Form
Table of Contents
Understanding the Do Not Resuscitate (DNR) Order form is crucial for individuals and families facing difficult healthcare decisions. This document allows patients to express their wishes regarding resuscitation efforts in the event of a medical emergency. It typically includes key information such as the patient’s name, date of birth, and a clear statement indicating their desire not to receive cardiopulmonary resuscitation (CPR) or other life-saving measures. The form is often signed by both the patient and their healthcare provider, ensuring that medical professionals are aware of and respect the patient’s wishes. Additionally, it may require witnesses to verify the authenticity of the signatures. Understanding the implications of a DNR order is essential, as it not only reflects personal values and beliefs but also guides healthcare providers in delivering care that aligns with the patient’s preferences. It is important to discuss these choices with family members and healthcare teams to ensure that everyone involved understands the patient's decisions and can advocate accordingly.
Documents used along the form
A Do Not Resuscitate (DNR) Order form is an important document that specifies an individual's wishes regarding resuscitation efforts in the event of a medical emergency. It is often accompanied by several other forms and documents that help ensure a person's healthcare preferences are respected. Below is a list of related documents that may be used alongside a DNR Order.
- Advance Healthcare Directive: This document outlines a person's preferences for medical treatment and appoints a healthcare proxy to make decisions on their behalf if they become unable to do so.
- Living Will: A type of advance directive, a living will specifies what types of medical treatment an individual wants or does not want in situations where they are unable to communicate their wishes.
- Healthcare Proxy Form: This form designates a specific person to make healthcare decisions for someone if they are incapacitated. It is crucial for ensuring that a trusted individual advocates for the patient’s preferences.
- Physician Orders for Life-Sustaining Treatment (POLST): A POLST form translates a patient's wishes regarding life-sustaining treatments into medical orders, guiding healthcare providers in emergencies.
- Power of Attorney for Healthcare: This legal document allows an individual to appoint someone to make healthcare decisions on their behalf, often used when the person cannot communicate their wishes.
- Quitclaim Deed: For straightforward property transfers, consider our comprehensive Quitclaim Deed guidelines to ensure all legal requirements are met.
- Do Not Intubate (DNI) Order: Similar to a DNR, a DNI order specifies that a patient does not want to be intubated or placed on a ventilator, focusing on breathing support preferences.
- Personal Health Record: This document compiles an individual's medical history, medications, allergies, and treatment preferences, providing a comprehensive overview for healthcare providers.
Understanding these forms can help ensure that your healthcare wishes are honored. It is advisable to discuss these documents with your healthcare provider and loved ones to ensure clarity and alignment with your values.
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Do Not Resuscitate Order Example
Do Not Resuscitate Order (DNR) - [State Name]
This Do Not Resuscitate Order (DNR) is made in accordance with the laws of [State Name]. This document expresses the wishes of the individual regarding resuscitation efforts in the event of a medical emergency.
Patient Information:
- Name: ___________________________
- Date of Birth: ____________________
- Address: _________________________
- Emergency Contact: _______________
Physician Information:
- Physician Name: ___________________
- Contact Number: ___________________
Order Statement:
I, the undersigned, declare that I do not wish to receive cardiopulmonary resuscitation (CPR) or any other life-sustaining treatment in the event that my heart stops beating or I stop breathing.
Conditions of Order:
This order is applicable in the following situations:
- Cardiac Arrest
- Respiratory Arrest
Patient’s Signature: ________________________
Date: ________________________
Witness Signature: ______________________
Date: ________________________
Additional Instructions:
Please notify all healthcare providers about this DNR order. It should be attached to the patient's medical records and be accessible to emergency medical personnel.
FAQ
What is a Do Not Resuscitate Order (DNR)?
A Do Not Resuscitate Order (DNR) is a legal document that instructs medical personnel not to perform cardiopulmonary resuscitation (CPR) in the event of cardiac arrest or respiratory failure. This order is typically put in place by individuals who have specific health conditions or preferences regarding end-of-life care. A DNR is often part of a broader advance directive, which may include other healthcare preferences.
Who can request a DNR order?
Typically, a DNR order can be requested by the patient themselves if they are of sound mind and capable of making healthcare decisions. In cases where the patient is unable to communicate their wishes, a legally authorized representative, such as a spouse, adult child, or designated healthcare proxy, may request the order. It's essential that the request aligns with the patient's values and medical condition.
How is a DNR order implemented?
To implement a DNR order, the following steps are usually taken:
- The patient or authorized representative discusses the decision with a healthcare provider.
- A formal DNR order is completed and signed by the physician, indicating the patient's wishes.
- The order is placed in the patient's medical record and must be accessible to all healthcare providers involved in the patient's care.
Additionally, it is advisable to keep a copy of the DNR order in a visible place, such as on the refrigerator or with the patient’s personal belongings, to ensure that emergency responders are aware of the order.
Can a DNR order be revoked?
Yes, a DNR order can be revoked at any time. The patient or authorized representative can communicate their decision to revoke the order verbally or in writing. Once the decision is made, it is important to inform all healthcare providers and ensure that the order is removed from the medical record. It is also recommended to keep a new copy of the updated wishes readily available to avoid confusion in emergency situations.
Key takeaways
Filling out a Do Not Resuscitate (DNR) Order form is an important step in expressing your healthcare wishes. Here are some key takeaways to keep in mind:
- Understand the Purpose: A DNR order informs medical personnel that you do not wish to receive CPR or other life-saving measures if your heart stops or you stop breathing.
- Consult with Your Healthcare Provider: Before completing the form, discuss your wishes with your doctor. They can help you understand the implications of a DNR order.
- Ensure Clarity: Make sure your wishes are clearly stated on the form. Ambiguities can lead to confusion during critical moments.
- Include Necessary Information: Fill out all required fields, including your name, date of birth, and any relevant medical history.
- Sign and Date: Your signature and the date are essential for the DNR order to be valid. Ensure it is signed by you or your legal representative.
- Notify Healthcare Providers: Share copies of the completed DNR order with your healthcare team, family members, and anyone involved in your care.
- Review Regularly: Your healthcare preferences may change over time. Review your DNR order periodically to ensure it still reflects your wishes.
- Keep It Accessible: Store the DNR order in a place where it can be easily found, such as on your refrigerator or in your medical file, to ensure it is available when needed.
PDF Form Breakdown
| Fact Name | Description |
|---|---|
| Definition | A Do Not Resuscitate (DNR) order is a legal document that instructs medical personnel not to perform cardiopulmonary resuscitation (CPR) in the event of cardiac arrest. |
| Purpose | The primary purpose of a DNR order is to honor the patient's wishes regarding end-of-life care, particularly when resuscitation may not align with their values or quality of life. |
| State Variability | Each state has its own laws governing DNR orders, which can affect the form's requirements and implementation. |
| Legal Authority | In many states, a DNR order must be signed by a physician and may also require the patient's signature or that of a legal representative. |
| Emergency Medical Services | Emergency medical personnel must be aware of and respect DNR orders. Some states have specific identification protocols, such as wearing a DNR bracelet. |
| Review and Revocation | Patients have the right to review and revoke their DNR orders at any time, ensuring that their preferences can evolve over time. |
| Advance Directives | A DNR order can be part of a broader advance directive, which outlines a person's healthcare preferences in various medical situations. |
| State-Specific Forms | Some states provide specific forms for DNR orders, such as California's Physician Orders for Life-Sustaining Treatment (POLST) or New York's DNR order form, governed by state law. |