Healthcare DNR Form

HEALTHCARE DO NOT RESUSCITATE (DNR) ORDER

This document records the patient's directive to withhold cardiopulmonary resuscitation in the event of cardiac or respiratory arrest. By completing and signing below, the patient or the patient's legally authorized representative affirms that this DNR order reflects the patient's informed choice. This DNR order is intended to be honored by healthcare professionals across care settings in accordance with applicable law and medical standards.

Patient Information

Patient Name:

Date of Birth:    Gender:

Medical and Advance Care Information

DNR Order — Direction

The undersigned directs that the following order be implemented in the event of cardiac or respiratory arrest. Select the option that reflects the patient's intent by checking the applicable box:

Do Not Resuscitate (No CPR). In the event of cardiac or respiratory arrest, chest compressions, defibrillation, endotracheal intubation, and advanced cardiac life support shall not be initiated.

No Advanced Cardiac Life Support (No ACLS). Basic life support measures may be considered for comfort only; advanced resuscitative interventions are not desired.

Allow Natural Death / Comfort-Focused Care. The goal of care is comfort; treatments intended solely to prolong life are not desired.

If multiple boxes are selected, the more restrictive order shall control. If none are checked, no DNR order is recorded on this form.

Scope and Application

This order applies across healthcare settings and applies only in circumstances of cardiac or respiratory arrest unless otherwise indicated here:

Health Care Agent / Surrogate

Relationship:    Phone:

Durable Power of Attorney for Health Care exists:

Effect, Revocation, and Rights

I understand that by signing this form I am directing that resuscitative measures specified above be withheld in the event of cardiac or respiratory arrest. This order may be revoked or amended by me at any time by a written revocation, a signed replacement order, or by informing a treating clinician in a manner documented in the medical record. I understand that I retain the right to refuse or withdraw this order, and that withdrawing this order will be documented in my medical record.

Witness Attestation

The undersigned witness(es) attest that the patient appeared to be of sound mind and acting voluntarily when signing this DNR order, that no undue influence was apparent, and that the witness is not the attending physician, not a health care provider directly responsible for the patient's care, and is not the named health care agent unless otherwise permitted by applicable law.

Witness Signature:    Date:

Physician / Clinician Attestation (Medical Order)

The clinician below attests that the above order reflects the patient's preferences and is consistent with the patient's medical condition and standard clinical practice. The clinician authorizes this DNR order as a medical order to be placed in the medical record and communicated to other treating clinicians.

Facility / Clinic:    Phone:

Physician Signature:    Date:

Legal Notice and Certification

By signing below, I certify that the information I have provided is true to the best of my knowledge, that I understand the nature and consequences of this DNR order, and that this order reflects my informed decision or the informed decision of the person for whom I am authorized to sign. This form is intended to serve as a medical order and should be honored by healthcare professionals consistent with applicable law and clinical practice.

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