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Free Do Not Resuscitate Order Form

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Do Not Resuscitate Order - Designed for Individual States

Do Not Resuscitate Order Sample

Do Not Resuscitate Order Template

This Do Not Resuscitate (DNR) Order is a legal document that clearly states your wishes regarding resuscitation in accordance with the laws of [State Name]. It is essential to complete this document so that your healthcare providers are aware of your preferences.

Please fill in the blanks below:

  • Patient's Full Name: ______________________________
  • Date of Birth: ______________________________
  • Address: ____________________________________
  • City, State, Zip Code: __________________________
  • Phone Number: _______________________________

This document states:

  1. The patient does not wish to receive cardiopulmonary resuscitation (CPR) or other resuscitative measures if they suffer a cardiac arrest.
  2. This directive applies only when the patient is unable to make decisions regarding their medical care.
  3. Healthcare providers must honor this DNR order in accordance with the laws of [State Name].

Patient's Signature: ______________________________ Date: _____________________

Witness Signature: ______________________________ Date: _____________________

Note: It is recommended to keep a copy of this order in a readily accessible location, and share it with your healthcare providers and family members.

⇓ PDF File

Instructions on Utilizing Do Not Resuscitate Order

Completing a Do Not Resuscitate (DNR) Order form is an important step in expressing your healthcare preferences. It is crucial to ensure that your wishes are clearly documented. Follow these steps carefully to fill out the form accurately.

  1. Obtain the DNR Order form. You can typically find this form at your healthcare provider's office, hospital, or online through reputable health organizations.
  2. Read the instructions. Take a moment to review any accompanying instructions or guidelines that come with the form. This will help clarify any specific requirements.
  3. Fill in your personal information. Provide your full name, date of birth, and any other requested identifying details. Ensure that the information is accurate to avoid any confusion later.
  4. Designate a healthcare proxy. If applicable, name a person who will make medical decisions on your behalf. This should be someone you trust to honor your wishes.
  5. Specify your wishes. Clearly indicate your desire for a Do Not Resuscitate order. You may need to check a box or sign a statement confirming your choice.
  6. Sign and date the form. Your signature is crucial as it validates the document. Make sure to date it appropriately.
  7. Consult with your physician. Schedule a meeting with your healthcare provider to discuss the form. They may need to sign it or provide additional information.
  8. Distribute copies. Once the form is completed and signed, make copies. Share them with your healthcare provider, family members, and anyone else involved in your care.
  9. Store the original safely. Keep the original document in a secure place where it can be easily accessed by your healthcare team when needed.

By following these steps, you can ensure that your DNR Order form is filled out correctly and reflects your wishes. It is essential to communicate openly with your loved ones and healthcare providers about your decisions to ensure that your preferences are respected.

Misconceptions

The Do Not Resuscitate (DNR) Order form is often misunderstood. Here are four common misconceptions:

  • A DNR means no medical care will be provided. Many people believe that having a DNR in place means they will not receive any medical attention. In reality, a DNR specifically refers to not performing cardiopulmonary resuscitation (CPR) in the event of cardiac arrest. Other medical treatments and care continue as needed.
  • A DNR is only for terminally ill patients. Some think that only those with terminal illnesses should have a DNR. However, anyone can choose to have a DNR, regardless of their health status. It’s a personal decision based on individual preferences about end-of-life care.
  • A DNR is permanent and cannot be changed. Many assume that once a DNR is signed, it cannot be altered. This is incorrect. A DNR can be revoked or modified at any time by the patient or their authorized representative, as long as they are capable of making that decision.
  • A DNR is the same as a living will. There is a misconception that a DNR and a living will are interchangeable. While both documents relate to end-of-life decisions, a living will provides broader guidance on medical treatment preferences, whereas a DNR specifically addresses resuscitation efforts.

Documents used along the form

A Do Not Resuscitate (DNR) Order is an important document that outlines a person's wishes regarding medical treatment in the event of a cardiac arrest. It is often accompanied by other forms and documents that help clarify a patient's healthcare preferences. Below are some common documents that may be used alongside a DNR Order.

  • Advance Directive: This legal document allows individuals to specify their healthcare preferences in advance. It can include instructions about medical treatments, end-of-life care, and appointing a healthcare proxy to make decisions on their behalf if they become unable to do so.
  • Healthcare Proxy: Also known as a durable power of attorney for healthcare, this document designates a specific person to make medical decisions for someone if they are incapacitated. It ensures that a trusted individual is empowered to act according to the patient’s wishes.
  • Non-disclosure Agreement (NDA): This legal document can be invaluable for individuals and businesses that need to share sensitive information securely. For more information, visit https://nypdfforms.com/non-disclosure-agreement-form.
  • Living Will: A living will is a type of advance directive that specifically addresses the types of medical treatment an individual wishes to receive or avoid in situations where they are unable to communicate their preferences. This document focuses on end-of-life care decisions.
  • Physician Orders for Life-Sustaining Treatment (POLST): This form translates a patient’s preferences regarding life-sustaining treatments into actionable medical orders. It is typically used for individuals with serious illnesses and provides clear instructions for emergency medical personnel.

Understanding these documents is essential for ensuring that your healthcare wishes are respected and followed. Each form plays a vital role in communicating preferences and appointing trusted individuals to advocate for you when necessary. Always consult with healthcare professionals and legal advisors to ensure these documents align with your values and intentions.