Homepage Free Do Not Resuscitate Order Form Attorney-Verified Do Not Resuscitate Order Template for California

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California Do Not Resuscitate Order (DNR)

This Do Not Resuscitate Order is created in accordance with the California Health and Safety Code Section 7190 et seq. It is intended to provide clear instructions regarding your preferences for medical treatment in the event that you are unable to communicate your wishes.

Patient Information:

  • Patient Name: ______________________________
  • Date of Birth: _____________________________
  • Address: ___________________________________________

Physician Information:

  • Physician's Name: ___________________________
  • Phone Number: _____________________________
  • Address: ___________________________________________

Emergency Contact:

  • Name: ______________________________________
  • Relationship: ____________________________
  • Phone Number: ____________________________

Instructions:

By signing this document, I express my wish to not receive cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest. This DNR Order is to be honored by all healthcare providers.

Person Making the Request:

  • Name: ______________________________________
  • Signature: _________________________________
  • Date: _____________________________________

Witnesses:

  1. Witness 1 Name: __________________________
  2. Witness 1 Signature: ______________________
  3. Date: _____________________________________
  1. Witness 2 Name: __________________________
  2. Witness 2 Signature: ______________________
  3. Date: _____________________________________

Please keep a copy of this Do Not Resuscitate Order in a place where it can be easily accessed by your healthcare providers and emergency personnel.

Documents used along the form

When considering end-of-life care options, individuals may encounter various forms and documents alongside the California Do Not Resuscitate (DNR) Order. Each of these documents serves a unique purpose, helping to ensure that a person's healthcare preferences are respected. Understanding these documents can aid in making informed decisions regarding medical treatment.

  • Advance Healthcare Directive: This document allows individuals to specify their healthcare preferences and appoint a healthcare agent to make decisions on their behalf if they become unable to do so.
  • Physician Orders for Life-Sustaining Treatment (POLST): POLST is a medical order that outlines a patient’s preferences for life-sustaining treatments, such as resuscitation and other interventions, based on their current health status.
  • Durable Power of Attorney: This essential form allows you to assign someone to manage your financial and personal affairs when you are unable to do so, providing peace of mind for you and your loved ones. For more information, visit Durable Power of Attorney.
  • Living Will: A living will is a type of advance directive that provides guidance on an individual’s wishes regarding medical treatment in situations where they cannot communicate their preferences.
  • Power of Attorney for Healthcare: This legal document designates someone to make medical decisions for an individual if they are unable to do so, ensuring that their wishes are followed.
  • Do Not Intubate (DNI) Order: A DNI order specifies that a patient should not be intubated or placed on a ventilator, providing clarity on their wishes regarding respiratory support.
  • Comfort Care Orders: These orders focus on providing comfort and alleviating pain rather than pursuing aggressive treatments, emphasizing quality of life.
  • Medication Administration Record: This document tracks all medications administered to a patient, ensuring that their treatment aligns with their preferences and needs.
  • Hospital Discharge Instructions: These instructions provide essential information for patients leaving the hospital, including follow-up care and medication management, which can be important for ongoing health decisions.
  • Patient's Rights Document: This document outlines the rights of patients within the healthcare system, ensuring they are informed about their care and treatment options.

By familiarizing oneself with these forms, individuals can better navigate the complexities of healthcare decisions and ensure their wishes are honored. Each document plays a crucial role in the overall planning process, contributing to a comprehensive approach to end-of-life care.

Similar forms

  • Advance Healthcare Directive: This document outlines a person's preferences for medical treatment in situations where they cannot communicate their wishes. Like a DNR, it allows individuals to express their desires regarding life-sustaining treatments.
  • Doctors Excuse Note: This form serves as an essential tool for individuals to provide verification of their medical condition and the necessity for absence from work or school. Ensure you complete the form by visiting doctorsnotetemplate.com/doctors-excuse-note-form.
  • Living Will: A living will specifies the types of medical care a person wishes to receive or avoid at the end of life. It shares similarities with a DNR in that both documents guide healthcare providers on treatment preferences.
  • Healthcare Power of Attorney: This form designates someone to make medical decisions on behalf of another person. It is similar to a DNR because it can include instructions about resuscitation and other critical care decisions.
  • POLST (Physician Orders for Life-Sustaining Treatment): A POLST form provides specific medical orders regarding treatment preferences. Like a DNR, it is designed for individuals with serious health conditions and must be honored by medical professionals.
  • Do Not Intubate (DNI) Order: This order specifically instructs healthcare providers not to insert a breathing tube. It is related to a DNR as both documents focus on limiting life-sustaining interventions.
  • Comfort Care Order: This document emphasizes the importance of comfort and quality of life rather than aggressive treatment. It aligns with a DNR by prioritizing patient comfort over resuscitation efforts.
  • Medical Orders for Scope of Treatment (MOST): Similar to a POLST, this form outlines a person's treatment preferences in detail. It serves as a guide for healthcare providers, much like a DNR, ensuring the patient's wishes are respected.

Misconceptions

Understanding the California Do Not Resuscitate (DNR) Order form is essential for making informed healthcare decisions. However, several misconceptions can lead to confusion. Here are five common misunderstandings:

  1. A DNR means no medical care at all.

    This is incorrect. A DNR order specifically addresses resuscitation efforts in the event of cardiac arrest. Patients with a DNR can still receive other medical treatments and interventions, including pain management and comfort care.

  2. Only terminally ill patients can have a DNR.

    This misconception overlooks the fact that anyone can choose to have a DNR order, regardless of their current health status. It is a personal decision based on individual values and preferences.

  3. A DNR is a legally binding document in all situations.

    While a DNR order is a legal document, its enforcement can vary based on the setting. For example, emergency medical services (EMS) may not honor a DNR in certain circumstances, such as when a patient is in a public place.

  4. A DNR order can only be created by a doctor.

    Patients or their legal representatives can initiate the DNR process. While a physician must sign the order, discussions about the desire for a DNR can begin with family members or healthcare providers.

  5. A DNR order is permanent and cannot be changed.

    This is a misconception. A DNR order can be revoked or modified at any time by the patient or their authorized representative. It is important for individuals to communicate their wishes clearly and update the order as needed.

Understanding these points can help individuals make informed decisions about their healthcare preferences and ensure their wishes are respected in critical situations.

Understanding California Do Not Resuscitate Order

  1. What is a Do Not Resuscitate (DNR) Order?

    A Do Not Resuscitate Order is a medical order that instructs healthcare providers not to perform cardiopulmonary resuscitation (CPR) in the event of cardiac arrest. This order is typically put in place for individuals who wish to avoid aggressive life-saving measures in certain medical situations.

  2. Who can request a DNR Order in California?

    In California, a DNR Order can be requested by a patient who is of sound mind, or by their legal representative if the patient is unable to make decisions. It is important that the individual understands the implications of the order before it is signed.

  3. How do I obtain a DNR Order form?

    DNR Order forms can be obtained from various sources, including hospitals, healthcare providers, and online resources from the California Department of Public Health. It’s essential to use the official form to ensure it is recognized by medical personnel.

  4. What information is required on the DNR Order form?

    The DNR Order form typically requires the patient’s name, date of birth, and signature, along with the signature of a physician. It may also include information about the patient's medical condition and preferences regarding end-of-life care.

  5. Where should I keep my DNR Order?

    It is advisable to keep the DNR Order in a location that is easily accessible, such as a medical file at home or with a trusted family member. Additionally, you should provide copies to your healthcare provider and any facility where you may receive care.

  6. Can a DNR Order be revoked?

    Yes, a DNR Order can be revoked at any time by the patient or their legal representative. To revoke the order, simply destroy the existing form and notify your healthcare provider of the change in your wishes.

  7. Will a DNR Order affect other types of medical treatment?

    A DNR Order specifically addresses resuscitation efforts during cardiac arrest. It does not impact other medical treatments or interventions. Healthcare providers will continue to provide appropriate care and treatment as needed, unless otherwise specified.