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Blank Do Not Resuscitate Order Form for Pennsylvania State

A Pennsylvania Do Not Resuscitate (DNR) Order form is a legal document that allows individuals to express their wishes regarding resuscitation efforts in the event of a medical emergency. This form ensures that patients receive care aligned with their personal values and preferences, particularly when facing life-threatening situations. To take control of your healthcare decisions, consider filling out the form by clicking the button below.

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Table of Contents

Document Overview

Fact Name	Description
Governing Law	The Pennsylvania Do Not Resuscitate Order is governed by the Pennsylvania Consolidated Statutes, Title 20, Chapter 54.
Purpose	This form allows individuals to express their wishes regarding resuscitation in the event of a medical emergency.
Eligibility	Any adult capable of making medical decisions can complete a Do Not Resuscitate Order.
Signature Requirements	The form must be signed by the patient and a physician to be valid.

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Documents used along the form

The Pennsylvania Do Not Resuscitate (DNR) Order form is an important document that allows individuals to express their wishes regarding resuscitation efforts in case of a medical emergency. In addition to the DNR form, there are several other documents that may be used to ensure a person's healthcare preferences are honored. Here are five commonly used forms and documents that often accompany a DNR Order in Pennsylvania.

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 communicate.
Living Will: A living will specifies the types of medical treatment an individual wishes to receive or avoid in situations where they are terminally ill or in a state of permanent unconsciousness.
Healthcare Power of Attorney: This legal document grants a designated person the authority to make healthcare decisions for someone else if they are incapacitated. It can be used in conjunction with a DNR order.
Physician Orders for Life-Sustaining Treatment (POLST): POLST is a medical order that details a patient's preferences for life-sustaining treatments, such as resuscitation and other interventions. It is designed for those with serious illnesses or frailty.
Medical Record Documentation: Healthcare providers often maintain records that include DNR orders and other advance directives. These documents ensure that medical staff are aware of a patient's wishes in emergency situations.

Understanding these forms and how they relate to the DNR Order can help individuals make informed decisions about their healthcare preferences. It is essential to ensure that all documents are completed correctly and shared with relevant parties, including healthcare providers and family members, to ensure wishes are respected in critical situations.

Document Sample

Pennsylvania Do Not Resuscitate Order (DNR)

This document serves as a Do Not Resuscitate Order (DNR) for individuals in the state of Pennsylvania. It is important to ensure that your wishes regarding resuscitation efforts are clearly documented. This template complies with Pennsylvania laws concerning DNR orders.

Patient Information:

Name: ________________________
Date of Birth: ___________________
Address: _______________________
City, State, Zip Code: _______________

Health Care Representative (if applicable):

Name: ________________________
Relationship to Patient: ________________
Phone Number: ____________________
Address: _______________________
City, State, Zip Code: _______________

Order Statement:

I, the undersigned, do hereby declare that if my heart stops beating or if I stop breathing, I do not want any attempts to resuscitate me, including, but not limited to:

Cardiopulmonary resuscitation (CPR)
Defibrillation
Advanced airway management

Patient Signature:

_________________________ Date: ____________

Witness Signature:

_________________________ Date: ____________

This document should be honored by all health care providers. Keep a copy with you at all times and provide copies to your health care representative and medical team.