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Printable Do Not Resuscitate Order Form

A Do Not Resuscitate Order (DNR) is a legal document that allows individuals to refuse resuscitation efforts in the event of a medical emergency. This form ensures that a person's wishes regarding end-of-life care are respected, providing peace of mind for both the individual and their loved ones. Understanding how to properly complete a DNR form is essential for those who wish to make informed decisions about their healthcare.

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Table of Contents

Do Not Resuscitate Order for Individual States

Document Overview

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 respect a patient's wishes regarding end-of-life care, ensuring that they do not undergo unwanted medical interventions.
Legal Authority	In the United States, DNR orders are governed by state laws, which vary significantly. For example, California's DNR orders are regulated under the California Health and Safety Code.
Patient Autonomy	DNR orders empower patients to make decisions about their own healthcare, reflecting their values and preferences regarding life-sustaining treatment.
Form Requirements	Most states require a DNR order to be signed by both the patient (or their legal representative) and a physician, ensuring that the decision is informed and consensual.
Emergency Medical Services	Emergency Medical Services (EMS) personnel are trained to recognize and honor DNR orders, provided that the order meets state-specific legal requirements.
Revocation	A DNR order can be revoked at any time by the patient or their legal representative, allowing for changes in their wishes regarding resuscitation.

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Documents used along the form

A Do Not Resuscitate (DNR) Order is an important document that outlines a patient's wishes regarding resuscitation efforts in the event of cardiac arrest. However, several other forms and documents often accompany a DNR to provide comprehensive guidance on a patient's healthcare preferences. Below is a list of these related documents.

Advance Healthcare Directive: This document allows individuals to specify their healthcare preferences and appoint a healthcare proxy to make decisions on their behalf if they become incapacitated.
Living Will: A living will outlines a person's wishes regarding medical treatment in situations where they cannot communicate their decisions, particularly concerning end-of-life care.
Healthcare Power of Attorney: This legal document designates someone to make medical decisions for an individual if they are unable to do so themselves, ensuring that their healthcare wishes are honored.
POLST Form (Physician Orders for Life-Sustaining Treatment): This form translates a patient's wishes regarding life-sustaining treatments into actionable medical orders, guiding healthcare providers in emergencies.
Patient's Bill of Rights: This document outlines the rights that patients have regarding their healthcare, including the right to make informed decisions about their treatment.
Do Not Intubate Order: Similar to a DNR, this order specifies that a patient does not wish to be intubated in the event of respiratory failure, providing clarity on their preferences.
Medical Record Release Authorization: This form allows patients to authorize the sharing of their medical records with designated individuals or entities, facilitating informed decision-making by healthcare proxies.
End-of-Life Care Plan: This document outlines a comprehensive approach to a patient’s care preferences at the end of life, including pain management and emotional support considerations.

Understanding these documents is crucial for ensuring that patients' wishes are respected and followed. They work together to create a clear picture of a person's healthcare preferences, especially during critical moments. Having these forms in place can provide peace of mind for both patients and their families.

Document Sample

Do Not Resuscitate Order (DNR) Template

This template serves as a Do Not Resuscitate (DNR) order in accordance with the laws of [State Name] regarding medical decisions and advance directives.

Patient Information

Please fill out the information below:

Patient's Full Name: ______________________________
Date of Birth: ______________________________
Address: ______________________________
Phone Number: ______________________________
Emergency Contact Name: ______________________________
Emergency Contact Phone Number: ______________________________

Directive Statement

I, [Patient's Full Name], am of sound mind and understand this document. I hereby declare that in the event of cardiac arrest or respiratory arrest, I do not wish to receive cardiopulmonary resuscitation (CPR) or any other life-sustaining measures to restore my heartbeat or breathing.

Additional Preferences

It is important to convey any additional preferences regarding end-of-life care:

Preferred Healthcare Facility: ______________________________
Specific Medical Preferences: ______________________________
Other Considerations: ______________________________

Signatures

This Do Not Resuscitate Order becomes effective immediately upon signing:

Patient Signature: ______________________________ Date: ________________
Witness Signature: ______________________________ Date: ________________
Healthcare Provider Signature: ______________________________ Date: ________________

It is recommended that a copy of this DNR order be kept in the patient's medical record and with other important documents.