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Do Not Resuscitate Order - Customized for State

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Do Not Resuscitate Order (DNR) - [State Name]

This Do Not Resuscitate Order (DNR) is made in accordance with the laws of [State Name]. It reflects my wishes regarding medical treatment in the event of cardiac arrest or respiratory failure.

Individual Information:

  • Full Name: ____________________________
  • Date of Birth: ____________________________
  • Address: ____________________________
  • Phone Number: ____________________________

Health Care Provider Information:

  • Health Care Provider Name: ____________________________
  • Facility Name: ____________________________
  • Phone Number: ____________________________

I, the undersigned, hereby declare that I do not wish to receive cardiopulmonary resuscitation (CPR) in the event of a medical emergency where I am not breathing or my heart has stopped beating. I understand that this order may affect my treatment options.

Signature: ____________________________

Date: ____________________________

This DNR Order will remain effective until revoked in writing by me or until my medical condition changes.

Witness:

Name: ____________________________

Signature: ____________________________

Date: ____________________________

Documents used along the form

A Do Not Resuscitate Order (DNR) form is an important document that outlines a person's wishes regarding resuscitation efforts in the event of a medical emergency. Along with the DNR, several other forms and documents are often utilized to ensure that an individual’s healthcare preferences are clearly communicated and respected. Below is a list of related documents that may accompany a DNR order.

  • Advance Healthcare Directive: This document allows individuals to specify their healthcare preferences in advance, including decisions about medical treatment and end-of-life care. It can include a living will and appoint a healthcare proxy.
  • Healthcare Power of Attorney: This legal document designates a trusted person to make medical decisions on behalf of an individual if they become unable to do so themselves. It ensures that someone familiar with their wishes is making choices during critical times.
  • Living Will: A living will is a type of advance directive that specifically addresses the types of medical treatments an individual wishes to receive or avoid in the event of a terminal illness or incapacitation.
  • ATV Bill of Sale: If you're engaged in the sale or purchase of an all-terrain vehicle, having an ATV Bill of Sale form is crucial for legal documentation and ensuring a smooth transfer of ownership.
  • Physician Orders for Life-Sustaining Treatment (POLST): This form translates a patient’s wishes regarding life-sustaining treatment into actionable medical orders. It is typically used for individuals with serious health conditions and is signed by a healthcare provider.

These documents work together to create a comprehensive plan that reflects an individual’s healthcare preferences. It is crucial to ensure that all relevant forms are completed and accessible to healthcare providers to honor the individual’s wishes effectively.

Similar forms

  • Advance Directive: An advance directive is a legal document that outlines a person's preferences regarding medical treatment in the event they become unable to communicate their wishes. Like a Do Not Resuscitate Order (DNR), it serves to guide healthcare providers in making decisions that align with the patient's values and desires.
  • Living Will: A living will is a specific type of advance directive that details the types of medical treatments a person does or does not want at the end of life. Similar to a DNR, it provides clear instructions to healthcare professionals about the individual's treatment preferences, particularly in critical situations.
  • Georgia Bill of Sale: This document is essential for transferring ownership of personal property, ensuring that both parties are protected in the transaction. You can find a template and additional information at legalpdfdocs.com/.
  • Healthcare Power of Attorney: This document designates an individual to make healthcare decisions on behalf of someone who is incapacitated. While a DNR focuses specifically on resuscitation efforts, a healthcare power of attorney can encompass a broader range of medical decisions, ensuring that the appointed person can act according to the patient's wishes.
  • Physician Orders for Life-Sustaining Treatment (POLST): A POLST form is a medical order that specifies a patient’s preferences for life-sustaining treatments. Like a DNR, it is intended for individuals with serious health conditions and must be signed by a healthcare provider, ensuring that the patient’s wishes are respected in emergency situations.

Misconceptions

The Do Not Resuscitate (DNR) Order form is often misunderstood. Here are nine common misconceptions that people may have about it:

  1. A DNR means no medical care at all.

    This is incorrect. A DNR specifically pertains to the withholding of CPR and other resuscitative measures. It does not prevent other forms of medical care, including pain management or comfort measures.

  2. Only terminally ill patients need a DNR.

    While many DNR orders are associated with terminal illnesses, anyone can request a DNR based on their personal wishes regarding end-of-life care. It’s about individual choice, not just illness status.

  3. A DNR is a permanent decision.

    This is a misconception. A DNR can be revoked or modified at any time by the patient or their legal representative. It’s important to communicate any changes to healthcare providers.

  4. Having a DNR means giving up hope.

    Many people believe that requesting a DNR signifies a lack of hope. In reality, it can be a thoughtful decision that reflects a desire for a peaceful end-of-life experience, rather than aggressive interventions.

  5. All healthcare providers respect DNR orders.

    While most do, there can be instances where confusion arises, especially in emergency situations. It’s crucial to ensure that the DNR is clearly documented and accessible to all medical personnel involved in care.

  6. A DNR is only for older adults.

    This belief is misleading. DNR orders can be requested by individuals of any age who wish to express their preferences regarding resuscitation efforts.

  7. You need a lawyer to create a DNR.

    Creating a DNR does not require legal assistance. Most healthcare facilities provide the necessary forms, and individuals can discuss their wishes directly with their healthcare providers.

  8. A DNR is the same as a living will.

    While both documents pertain to end-of-life care, they serve different purposes. A living will outlines a person's wishes regarding medical treatment in various situations, while a DNR specifically addresses resuscitation efforts.

  9. Once signed, a DNR cannot be changed.

    This is not true. Patients can review and change their DNR orders as their health status or preferences evolve. Communication with healthcare providers is key to ensuring that the DNR reflects current wishes.

Understanding Do Not Resuscitate Order

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

    A Do Not Resuscitate Order is a legal document that allows a person to refuse certain medical interventions, particularly cardiopulmonary resuscitation (CPR), in the event of a medical emergency. This order is typically used by individuals with serious health conditions who wish to avoid life-saving measures that may not align with their wishes for end-of-life care.

  2. Who can request a DNR Order?

    Generally, a DNR Order can be requested by any adult who is capable of making their own medical decisions. In cases where the individual is unable to communicate their wishes, a legally authorized representative, such as a family member or healthcare proxy, may be able to request the order on their behalf.

  3. How is a DNR Order created?

    To create a DNR Order, the individual or their representative must typically fill out a specific form provided by a healthcare facility or state health department. This form often requires the signatures of both the patient and their physician. It’s important to ensure that the document is completed accurately and in accordance with state laws.

  4. Where should a DNR Order be kept?

    It is crucial to keep the DNR Order in a place that is easily accessible to medical personnel. Many people choose to keep a copy in their medical records, at home, or even on their refrigerator. Some states also provide identification bracelets or cards that indicate the presence of a DNR Order.

  5. Can a DNR Order be revoked?

    Yes, a DNR Order can be revoked at any time by the individual who created it. This can be done verbally or in writing, depending on state regulations. It is advisable to inform healthcare providers and family members about the revocation to ensure that everyone is aware of the change in wishes.

  6. Does a DNR Order apply outside of a hospital setting?

    The application of a DNR Order outside of a hospital can vary by state. In many cases, a DNR Order is valid in emergency situations outside of a medical facility, but it is important to check local laws and regulations. Some states have specific forms or procedures for DNR Orders that apply in various settings, including at home or in long-term care facilities.

  7. What should I discuss with my doctor before completing a DNR Order?

    Before completing a DNR Order, it is essential to have an open conversation with your healthcare provider. Discuss your health condition, prognosis, and the implications of refusing resuscitation. Understanding the potential outcomes and ensuring that your wishes align with your medical goals will help in making an informed decision.