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Free Do Not Resuscitate Order Template

A Do Not Resuscitate (DNR) Order is a legal document that allows individuals to express their wishes regarding medical treatment in emergencies, specifically the desire to forgo cardiopulmonary resuscitation (CPR). This form is crucial for ensuring that a person's preferences are respected when they are unable to communicate them. Understanding how to properly complete and implement a DNR Order can provide peace of mind for both patients and their families.

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Contents

State-specific Information for Do Not Resuscitate Order Forms

What to Know About This Form

What is a Do Not Resuscitate (DNR) Order?
A Do Not Resuscitate Order is a legal document that indicates a person's wishes regarding resuscitation efforts in the event of cardiac arrest or respiratory failure. When a DNR order is in place, medical personnel are instructed not to perform cardiopulmonary resuscitation (CPR) or other life-saving measures. This order is typically used by individuals with terminal illnesses or those who wish to avoid aggressive medical interventions at the end of life.
Who can request a DNR Order?
Generally, any adult who is capable of making informed decisions about their healthcare can request a DNR order. This includes patients who understand the implications of such a decision. In some cases, a legally authorized representative, such as a family member or healthcare proxy, may also request a DNR on behalf of a patient who is unable to do so.
How is a DNR Order created?
A DNR order is created by completing a specific form that varies by state. This form must be signed by the patient or their authorized representative and typically requires the signature of a physician. It is important to ensure that the form complies with state regulations to be considered valid. Once completed, the DNR order should be kept in a readily accessible location, such as with the patient’s medical records or at their residence.
Can a DNR Order be revoked?
Yes, a DNR order can be revoked at any time. The individual who created the order can simply inform their healthcare provider or remove the DNR document from its location. It is advisable to communicate any changes to family members and healthcare professionals to ensure that everyone is aware of the updated wishes regarding resuscitation.
What should I do if I have questions about a DNR Order?
If you have questions about a DNR order, it is important to discuss them with a healthcare professional. They can provide guidance on the implications of a DNR order and help clarify any concerns you may have. Additionally, legal advisors or patient advocacy groups can offer resources and support to assist you in understanding your options.

▼ Do Not Resuscitate Order PDF

Misconceptions

Many people have misunderstandings about the Do Not Resuscitate (DNR) Order form. Here are four common misconceptions:

A DNR means you are giving up on treatment. This is not true. A DNR simply indicates that you do not want to receive CPR or other resuscitation efforts in the event of a cardiac arrest. It does not prevent you from receiving other medical treatments.
A DNR is only for terminally ill patients. While many people with terminal illnesses choose to have a DNR, it is not limited to them. Anyone can request a DNR based on their personal health care preferences.
A DNR is permanent and cannot be changed. This misconception is false. A DNR can be revoked or modified at any time. You have the right to change your mind about resuscitation efforts whenever you wish.
Having a DNR means you will not receive any medical care. This is incorrect. A DNR only applies to resuscitation efforts. You will still receive all other necessary medical treatments and care as needed.

Understanding these misconceptions can help you make informed decisions about your health care preferences.

PDF Form Attributes

Fact Name	Details
Definition	A Do Not Resuscitate (DNR) Order is a medical order that prevents healthcare providers from performing cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest.
Legal Status	DNR Orders are legally recognized documents in all 50 states, but specific requirements may vary by state.
Governing Laws	Each state has its own laws governing DNR Orders. For example, California's DNR Orders are governed by the California Health and Safety Code, while New York's are covered under the New York Public Health Law.
Patient Consent	Patients or their legal representatives must provide consent for a DNR Order. This ensures that the patient's wishes are respected.
Form Requirements	Most states require a specific form to be completed for a DNR Order to be valid. This form typically needs to be signed by a physician.
Revocation	Patients have the right to revoke a DNR Order at any time. This can be done verbally or in writing, depending on state laws.
Communication	It is crucial for patients to communicate their DNR status to family members and healthcare providers to avoid confusion during emergencies.

Common mistakes

Failing to provide accurate personal information, such as full name and date of birth, can lead to confusion.
Not clearly indicating the patient's wishes can result in misunderstandings. Be specific about the desire for no resuscitation.
Forgetting to sign the form is a common mistake. A signature is necessary for the document to be valid.
Neglecting to date the form can create issues regarding its validity over time.
Using outdated forms may lead to legal complications. Always ensure you have the most current version.
Not discussing the order with family members can cause distress and confusion during critical moments.
Overlooking the need for witnesses, if required by state law, can invalidate the order.
Failing to review the form periodically may result in outdated wishes not being honored.
Not keeping copies of the signed form accessible can hinder its implementation when needed.

Preview - Do Not Resuscitate Order Form

Do Not Resuscitate Order (DNR) Template

This Do Not Resuscitate Order (DNR) is in accordance with the laws of [State Name]. It is intended for use in medical situations where the individual does not wish to receive cardiopulmonary resuscitation (CPR) or other life-sustaining treatments.

Please fill in the blanks with the necessary information to complete this order.

Patient's Name: ___________________________
Date of Birth: ___________________________
Address: ________________________________
Phone Number: __________________________
Primary Physician's Name: _______________
Primary Physician's Phone Number: ________

This order signifies that the patient listed above does not wish to receive CPR or any interventions intended to restore heart function or breathing in the event of a cardiac arrest or respiratory failure.

Signing Instructions:

All parties involved, including the patient (if applicable), healthcare proxy, and physician, should sign this document.
Ensure that copies of this order are provided to the patient’s healthcare provider and made available in medical records.
Review and update this order as needed, especially with changes to the patient’s health status or preferences.

Patient/Legal Guardian Signature: _______________ Date: ________________

Physician Signature: _______________ Date: ________________

This Do Not Resuscitate Order shall be honored in all healthcare settings. If you have questions about its implementation, consult a legal professional or healthcare provider.

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