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Attorney-Approved Do Not Resuscitate Order Template

A Do Not Resuscitate (DNR) Order is a medical directive that informs healthcare providers not to perform cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest. This form is crucial for individuals who wish to avoid aggressive life-saving measures in certain medical situations. Understanding the implications and procedures surrounding a DNR Order can empower patients and their families to make informed decisions about end-of-life care.

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Common Templates:

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State-specific Do Not Resuscitate Order Templates

➤ PDF File

Example - Do Not Resuscitate Order Form

Do Not Resuscitate Order (DNR)

This Do Not Resuscitate Order (DNR) is executed in accordance with the laws of [State Name]. This document allows individuals to communicate their wishes regarding resuscitation efforts in the event of a medical emergency.

By using this form, you are stating your desire to refuse resuscitation efforts should your heart stop beating or if you stop breathing naturally.

Patient Information

Patient's Full Name: ______________________________
Date of Birth: ______________________________
Patient's Address: ____________________________
City: ______________________ State: __________ Zip Code: __________

Health Care Provider Information

Health Care Provider's Name: _____________________________
Provider's Phone Number: _____________________________

Declaration

I, the undersigned, am of sound mind. I understand that by signing this document, it indicates that I do not wish to receive resuscitative measures in the event of an untreatable condition.

Signatures

Patient's Signature: _____________________________ Date: ________________
Witness Signature: _____________________________ Date: ________________

This document may be reviewed and updated periodically to reflect any changes in preferences or health status.

Please share copies of this DNR order with your health care provider and family members to ensure your wishes are honored.

Documents used along the form

A Do Not Resuscitate (DNR) Order form is an important document that communicates a person's wishes regarding resuscitation efforts in the event of a medical emergency. In addition to the DNR, several other forms and documents can provide clarity and support for patients and their families in making healthcare decisions. Below is a list of related documents that are often used alongside a DNR Order.

Advance Directive: This document outlines a person's preferences for medical treatment in situations where they cannot communicate their wishes. It may include instructions about life-sustaining treatments, organ donation, and more.
Living Will: A living will specifies the types of medical treatments an individual does or does not want in case of a terminal illness or incapacitation. It serves as a guide for healthcare providers and family members.
Healthcare Proxy: This form appoints a specific person to make medical decisions on behalf of the individual if they are unable to do so. The proxy should be someone who understands the individual’s values and wishes.
Physician Orders for Life-Sustaining Treatment (POLST): This is a medical order that outlines a patient's preferences for emergency medical treatment. It is designed for individuals with serious illnesses and is recognized by healthcare providers.
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Do Not Intubate (DNI) Order: Similar to a DNR, this order specifically states that a patient does not wish to be intubated or placed on a ventilator in case of respiratory failure.
Organ Donation Registration: This document allows individuals to register their wishes regarding organ donation. It can be included in an advance directive or submitted separately to a donor registry.
Patient Information Form: This form collects essential information about the patient, including medical history, current medications, and emergency contacts. It helps healthcare providers deliver appropriate care.
Medical Power of Attorney: This legal document designates an individual to make healthcare decisions on behalf of the patient if they become incapacitated. It is crucial for ensuring that the patient’s wishes are respected.

These documents work together to ensure that a person’s healthcare preferences are clearly communicated and honored. Having them in place can provide peace of mind for both patients and their families during challenging times.