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Blank Do Not Resuscitate Order Form for New York State

A New York Do Not Resuscitate Order (DNR) form is a legal document that allows individuals to express their wishes regarding resuscitation efforts in case of a medical emergency. By completing this form, you can ensure that your preferences are respected when it comes to life-saving measures. If you’re considering filling out this important document, click the button below to get started.

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Table of Contents

Document Overview

Fact Name	Details
Definition	A Do Not Resuscitate (DNR) Order is a medical order that prevents healthcare providers from performing CPR if a patient's heart stops beating or they stop breathing.
Governing Law	The New York Do Not Resuscitate Order is governed by New York Public Health Law, Article 29-B.
Eligibility	Any adult patient, or a parent or guardian of a minor, can request a DNR order.
Form Requirements	The DNR form must be signed by the patient or their legal representative and a physician.
Notification	Healthcare providers must be informed of the existence of a DNR order to ensure it is honored.
Validity	The DNR order remains valid until revoked by the patient or their representative.
Emergency Services	Emergency medical services (EMS) must follow the DNR order if it is properly completed and presented.
Form Accessibility	The New York DNR order form is available through healthcare facilities and online resources.
Patient Rights	Patients have the right to change their mind about the DNR order at any time.
Additional Documentation	In some cases, a living will or healthcare proxy may accompany the DNR order for clarity on patient wishes.

Download Do Not Resuscitate Order PDF Form

Discover More Do Not Resuscitate Order Templates for Specific States

What Is Dnr Mean - A DNR ensures medical staff respect a patient’s decision regarding resuscitation efforts.

Do Not Resuscitate Order - An advance directive may accompany a DNR to outline broader healthcare decisions.

Dnr Form California - A DNR order reflects a patient's values and goals for their life and medical care.

Documents used along the form

The New York Do Not Resuscitate (DNR) Order form is a crucial document for individuals who wish to express their preferences regarding resuscitation in the event of a medical emergency. However, it is often accompanied by other important forms and documents that further clarify a person's healthcare wishes. Below are four commonly used forms that may be utilized alongside the DNR Order.

Healthcare Proxy Form: This document allows an individual to appoint someone they trust to make healthcare decisions on their behalf if they become unable to do so. It ensures that a person's medical preferences are honored even when they cannot communicate them directly.
Living Will: A living will outlines specific medical treatments an individual wishes to receive or avoid in situations where they are unable to express their wishes. This document complements the DNR Order by providing additional context about a person's overall healthcare preferences.
Physician Orders for Life-Sustaining Treatment (POLST): The POLST form translates a patient's treatment preferences into actionable medical orders. It is particularly useful for those with serious illnesses, as it ensures that their wishes regarding life-sustaining treatments are respected by healthcare providers.
Advance Directive: An advance directive is a broader term that encompasses both the healthcare proxy and living will. It serves as a comprehensive guide to a person's healthcare preferences, helping to communicate their desires to family members and medical professionals.

These documents work together to create a clear and comprehensive picture of an individual's healthcare wishes. By understanding and utilizing these forms, individuals can ensure their preferences are respected, promoting peace of mind for themselves and their loved ones.

Document Sample

New York Do Not Resuscitate Order

This Do Not Resuscitate (DNR) Order follows the regulations established by New York State Public Health Law and reflects the wishes of the person named below.

Patient Information:

Patient Name: ____________________________
Date of Birth: ____________________________
Address: ____________________________

Medical Information:

Primary Physician: ____________________________
Phone Number: ____________________________

Declaration:

I, the undersigned, hereby request that resuscitation measures not be initiated or continued in the event that my heart stops beating or I stop breathing. I understand that this DNR Order will be effective until revoked or canceled by me.

Signature: __________________________________

Date: __________________________________

Witness Information:

Name: ____________________________
Signature: ____________________________
Date: ____________________________

This document should be placed in a location that is easily accessible to healthcare providers. It is also advisable to share copies of this DNR Order with family members and healthcare providers to ensure its proper enforcement.