Fill and Sign the Do Not Resuscitate Order Dnr or Advance Directive Form

Do Not Resuscitate Order (DNR) or Advance Directive 1. FULL CARDIOPULMONARY ARREST (When both breathing and heartbeat stop): [ ] Do Not Attempt Cardiopulmonary Resuscitation (CPR). (Measures to promote patient comfort and dignity will be provided.) 2. PRE-ARREST EMERGENCY (When breathing is labored or stopped, and heart is still beating): SELECT ONE [ ]Do Attempt Cardiopulmonary Resuscitation (CPR) –OR [ ] Do Not Attempt Cardiopulmonary Resuscitation (CPR) (Measures to promote patient comfort and dignity will be provided.) Other Instructions ________________________________________________________________ _______________________________________________________________________________ ________ ________ ________ ________ ________ ________ Patient Directive Authorization and Consent to DNR Order (Required to be a valid DNR Order) I understand and authorize the above Patient Directive, and consent to a physician DNR Order implement ing this Patient Directive. Printed Name of Individual _______________________________ Signature of Individual __________________________________ Date _____________ OR Printed Name of Individual ______________________________ Signature of Individual _________________________________ Date _____________ [ ] Legal Guardian or [ ] Agent under Health Care Power of Attorney or [ ] Health Care Surrogate Decision Maker ________ ________ ________ ________ ________ ________ Witness to Consent (Required to have two witnesses to be a valid DNR Order) I am 18 years of age or older and have witnessed the giving of consent by the above person. Printed Name of Witness _____________________________ Signature of Witness ________________________________ Date _____________ Printed Name of Witness _____________________________ Signature of Witness ________________________________ Date _____________ Physician Signature (Required to be a valid DNR Order) I hereby execute this DNR Order on this the _____ day of ___________, 20_____. __________________________ _____________________________ ___________ Signature of Attending Physician Printed Name of Attending Physician Date Send this form or a copy of both sides with the individual upon transfer or discharge. Do Not Resuscitate Order (DNR) or Advance Directive (Page 2 of 2) Patient’s Name _________________________________________ Summarize Medical Condition: _______________________________________________________ ________________________________________________________________________________ _________________________________________________________________________ When This Form Should Be Reviewed This DNR order, in effect until revoked, should be reviewed periodically, particularly if:  The patient/resident is transferred from one care setting or care level to another, or  There is a substantial change in patient/resident health status, or  The patient/resident treatment preferences change. How to Complete the Form Review 1. Review the other side of this form. 2. Complete the following section. If this form is to be voided, write "VOID" in large letters on the other side of the form. After voiding the form, a new form may be completed. Date Reviewer Location of Review Outcome of Review [ ] No change [ ] FORM VOIDED; new form completed [ ] FORM VOIDED; no new form completed Date Reviewer Location of Review Outcome of Review [ ] No change [ ] FORM VOIDED; new form completed [ ] FORM VOIDED; no new form completed Date Reviewer Location of Review Outcome of Review [ ] No change [ ] FORM VOIDED; new form completed [ ] FORM VOIDED; no new form completed Advanced Directive I also have the following advance directives: Contact Person (Name and Phone Number) [ ] Health Care Power of Attorney _______________________________________ [ ] Living Will _______________________________________ [ ] Mental Health Treatment _______________________________________ Preference Declaration Send this form or a copy of both sides with the individual upon transfer or discharge.