Official Do Not Resuscitate Order Template Open Do Not Resuscitate Order Editor Here

Official Do Not Resuscitate Order Template

A Do Not Resuscitate (DNR) Order is a legal document that informs medical personnel not to perform cardiopulmonary resuscitation (CPR) if a patient’s heart stops or they stop breathing. This order reflects the patient’s wishes regarding end-of-life care and can provide peace of mind for both patients and their families. To ensure your preferences are known, consider filling out the form by clicking the button below.

Open Do Not Resuscitate Order Editor Here

Key takeaways

Filling out a Do Not Resuscitate (DNR) Order form is a significant decision that requires careful consideration. Here are key takeaways to keep in mind:

  1. Understand the Purpose: A DNR order indicates that you do not wish to receive cardiopulmonary resuscitation (CPR) in the event of a cardiac arrest.
  2. Consult with Healthcare Providers: Discuss your wishes with your doctor or healthcare team. They can provide guidance tailored to your medical condition.
  3. Communicate Clearly: Ensure that your wishes are clearly stated on the DNR form. Ambiguities can lead to confusion during critical moments.
  4. Involve Family Members: Talk to your family about your decision. Their understanding and support can be invaluable in ensuring your wishes are respected.
  5. Review Legal Requirements: Different states have varying laws regarding DNR orders. Familiarize yourself with the regulations in your state.
  6. Keep the Form Accessible: Store the completed DNR form in a location where it can be easily found by medical personnel, such as with your medical records or on your refrigerator.
  7. Regularly Update the Order: Review your DNR order periodically, especially if your health status changes or if you have new medical information.
  8. Inform Emergency Contacts: Make sure that your emergency contacts are aware of your DNR order and know where to find it.
  9. Consider Additional Advance Directives: A DNR order is just one part of advance care planning. Consider creating a living will or appointing a healthcare proxy for comprehensive planning.

Making informed decisions about a DNR order can provide peace of mind for you and your loved ones. It is essential to approach this process with care and compassion.

Do Not Resuscitate Order Preview

Do Not Resuscitate Order (DNR) Template

This document serves as a Do Not Resuscitate (DNR) Order, following the requirements of [State Name] laws regarding advance directives and end-of-life care.

Patient Information

  • Name: _______________________________
  • Date of Birth: _______________________
  • Address: ____________________________
  • City, State, Zip: ____________________

Physician Information

  • Physician's Name: __________________ __
  • Physician's Phone Number: ____________
  • Facility: ____________________________

Declaration

I, the undersigned, declare that I do not wish to receive cardiopulmonary resuscitation (CPR) or other life-sustaining measures in the event of cardiac or respiratory arrest.

Rationale

The reasons for this decision include:

  1. _______________________________
  2. _______________________________
  3. _______________________________

Signature

This order is made voluntarily and reflects my wishes:

  • Patient Signature: ___________________
  • Date: ________________________________

Witness Information

  • Witness Name: _____________________
  • Witness Signature: __________________
  • Date: ________________________________

This Do Not Resuscitate Order should be kept in a location where it can be readily accessed by medical personnel in case of an emergency.

Similar forms

A Living Will is similar to a Do Not Resuscitate Order (DNR) in that both documents express a person's wishes regarding medical treatment in situations where they cannot communicate. A Living Will typically outlines specific treatments a person does or does not want, such as life-sustaining measures, while a DNR specifically addresses the desire not to receive cardiopulmonary resuscitation (CPR) in the event of cardiac arrest. Both documents serve to ensure that an individual's preferences are respected during critical medical situations.

A Healthcare Proxy allows an individual to appoint someone to make medical decisions on their behalf if they become unable to do so. Like a DNR, it focuses on medical care preferences, but instead of detailing specific treatments, it designates a trusted person to interpret and carry out the individual's wishes. This ensures that decisions align with the individual's values and desires, especially in emergencies where they cannot voice their choices.

A Medical Power of Attorney is another document that shares similarities with a DNR. It grants a designated person the authority to make healthcare decisions for someone else. While a DNR specifically instructs medical staff not to perform CPR, a Medical Power of Attorney can cover a broader range of medical decisions. Both documents are crucial for ensuring that medical care aligns with an individual's wishes.

An Advance Directive combines elements of a Living Will and a Healthcare Proxy. It allows individuals to outline their medical treatment preferences while also appointing someone to make decisions if they are incapacitated. Like a DNR, it provides clarity about what kind of medical interventions a person does or does not want, helping healthcare providers understand the patient’s wishes in critical situations.

A Do Not Intubate (DNI) order is closely related to a DNR. While a DNR instructs medical personnel not to perform CPR, a DNI specifically states that a patient does not wish to be placed on a ventilator or receive breathing assistance. Both orders reflect a patient’s preferences for end-of-life care and help guide healthcare providers in making decisions that respect those wishes.

An Organ Donation Consent form expresses an individual's wish to donate their organs after death. While it serves a different purpose than a DNR, both documents communicate important personal decisions regarding medical care and end-of-life preferences. An Organ Donation Consent form ensures that a person’s desire to contribute to saving lives is honored, just as a DNR ensures their wishes regarding resuscitation are respected.

A Do Not Hospitalize (DNH) order is similar to a DNR in that it reflects a patient’s desire to avoid certain medical interventions. A DNH order indicates that a patient does not wish to be admitted to a hospital for treatment, focusing on comfort care instead. Both documents emphasize the importance of respecting a patient’s wishes in the face of serious health issues.

A Comfort Care order prioritizes palliative care over curative treatment. While a DNR specifically addresses resuscitation efforts, a Comfort Care order focuses on providing relief from pain and stress without aggressive medical interventions. Both documents highlight a patient’s preferences for their care, ensuring that healthcare providers understand their desire for quality of life during serious illness.

In the context of healthcare decision-making and advanced planning, individuals may also need to consider forms relevant to their financial responsibilities, such as the California 3539 form, which can be conveniently accessed through California PDF Forms. This form ensures organized handling of tax obligations while individuals focus on their personal and medical directives.

A Palliative Care Plan outlines a patient's goals for care, emphasizing comfort and quality of life. Similar to a DNR, it reflects the individual’s values and preferences regarding medical treatment. While a DNR focuses on specific resuscitation efforts, a Palliative Care Plan provides a broader approach to managing symptoms and ensuring the patient’s wishes are honored throughout their illness.

How to Use Do Not Resuscitate Order

Filling out a Do Not Resuscitate (DNR) Order form is an important step in expressing your healthcare wishes. It ensures that your preferences are clearly documented and respected in medical situations. Here’s how to complete the form effectively.

  1. Begin by gathering any necessary personal information. This includes your full name, date of birth, and contact information.
  2. Identify the healthcare provider who will be signing the form. This could be your primary care physician or another licensed medical professional.
  3. Clearly state your wishes regarding resuscitation. This may involve checking a box or writing a statement that indicates your preference not to receive resuscitation efforts.
  4. Include any additional instructions or preferences regarding your care. This can help clarify your wishes further.
  5. Sign and date the form. Your signature confirms that you understand and agree with the contents of the document.
  6. Have your healthcare provider sign the form as well. Their signature is necessary for the DNR to be valid.
  7. Make copies of the completed form. Keep one for your records and provide copies to your healthcare provider, family members, and anyone else involved in your care.

Once you have filled out the form, ensure that it is stored in an accessible place. It’s important that your loved ones and healthcare team know where to find it when needed.

Documents used along the form

A Do Not Resuscitate (DNR) Order is an important document that outlines an individual's wishes regarding medical treatment in the event of cardiac arrest or respiratory failure. Along with the DNR, several other forms and documents may be used to ensure that a person's healthcare preferences are clearly communicated and respected. Here is a list of commonly associated documents:

  • Advance Healthcare Directive: This document allows individuals to specify their healthcare preferences and appoint a healthcare proxy to make decisions on their behalf if they become unable to do so.
  • Living Will: A living will outlines an individual's wishes regarding medical treatment and interventions in situations where they are terminally ill or permanently unconscious.
  • Healthcare Proxy: This form designates a specific person to make medical decisions for someone if they are unable to communicate their wishes due to illness or incapacity.
  • Physician Orders for Life-Sustaining Treatment (POLST): This document translates a patient’s preferences regarding life-sustaining treatments into actionable medical orders, ensuring they are followed by healthcare providers.
  • Durable Power of Attorney for Healthcare: This legal document allows an individual to appoint someone to make healthcare decisions on their behalf, even if they are not incapacitated.
  • Do Not Intubate (DNI) Order: Similar to a DNR, a DNI specifically indicates that a patient does not wish to be intubated or placed on a ventilator if they cannot breathe independently.
  • Employment Verification Form: This document serves to confirm an individual's employment history and status, crucial for processes such as background checks and loan applications. Understanding how to complete and use this form is essential, and you can find a helpful resource at https://templates-guide.com/california-employment-verification-template.
  • Patient Information Form: This form collects essential information about the patient, including medical history, allergies, and current medications, which helps healthcare providers make informed decisions.
  • Emergency Medical Services (EMS) DNR Form: This form is specifically designed for use by emergency medical services to ensure that a patient’s DNR wishes are honored in emergency situations.

Understanding these documents can help individuals and their families navigate complex healthcare decisions. Each form plays a vital role in ensuring that a person's medical preferences are honored, particularly in critical situations.

Common mistakes

  1. Not Understanding the Form: Many individuals fail to fully comprehend the implications of a Do Not Resuscitate (DNR) Order. This can lead to decisions that do not align with their true wishes regarding end-of-life care.

  2. Inadequate Communication: Some people neglect to discuss their DNR wishes with family members or healthcare providers. This can result in confusion and conflict during critical moments when decisions must be made.

  3. Incorrect Completion: Mistakes in filling out the form, such as missing signatures or dates, can render the DNR Order invalid. It is essential to follow all instructions carefully to ensure the document is legally binding.

  4. Not Updating the Order: Life circumstances can change, and so can personal wishes. Failing to review and update the DNR Order can lead to situations where the document no longer reflects an individual’s current preferences.

  5. Ignoring State-Specific Laws: Each state has its own regulations regarding DNR Orders. People often overlook these legal requirements, which can affect the enforcement of their wishes.

  6. Assuming Verbal Agreements are Sufficient: Some individuals believe that simply communicating their wishes verbally is enough. However, without a formalized DNR Order, healthcare providers may not honor those wishes.

  7. Failing to Keep Copies Accessible: After completing the DNR Order, it is crucial to keep copies in easily accessible locations. Not having the document readily available can lead to unintended resuscitation efforts.

Dos and Don'ts

When filling out a Do Not Resuscitate (DNR) Order form, it's important to follow specific guidelines to ensure your wishes are clearly communicated. Here’s a list of things to do and avoid:

  • Do discuss your wishes with your healthcare provider.
  • Do ensure that the form is signed by you and a witness, if required.
  • Do keep a copy of the signed form in a visible place.
  • Do inform family members about your DNR decision.
  • Don't leave any sections of the form blank.
  • Don't assume that verbal instructions are enough; always use the form.
  • Don't forget to review and update the form as needed.