Healthcare DNR Reel

HEALTHCARE DNR ORDER AND ACKNOWLEDGMENT

Patient Information

Date of Birth:    Gender: Male Female Other

Primary Phone:    Emergency Contact:    Relationship:    Phone:

Advance Directive / Surrogate

Advance Directive on file: Yes    No:    Healthcare Proxy / Agent Name:    Proxy Phone:

DNR Order (Medical Order)

I direct that, in the event of cardiopulmonary arrest, the following orders be observed (check all that apply):

Do Not Attempt Cardiopulmonary Resuscitation (DNR/No CPR) — withhold chest compressions, defibrillation, endotracheal intubation and advanced airway management for cardiopulmonary arrest.
Do Not Intubate (DNI) — do not perform endotracheal intubation; other interventions may be applied per order below.
Comfort Measures Only — provide treatments to relieve pain and suffering; avoid life-prolonging interventions inconsistent with comfort-focused care.
Allow limited/other specified treatments (describe below):

Scope of this order applies to: In-hospital settings Out-of-hospital / Emergency Medical Services All settings unless revoked

Authorization Expiration Date (if any):

Acknowledgment and Explanation

I acknowledge that I have received a clear explanation of the orders checked above, including the likely benefits, burdens and reasonably foreseeable risks of the selected orders and of the alternatives to those orders. I understand that:

• These orders apply when the patient has no signs of circulation and respiration.
• The patient or legally authorized decision-maker has the right to revoke or change these orders at any time while the patient has capacity, or as allowed by law.
• These orders will be honored by hospital staff and emergency medical responders to the extent permitted by law and clinical circumstances.

Clinical Justification / Medical Record Summary

Physician Order and Attestation

Attending Physician Name:

License / NPI or Provider ID:    Facility:

Basis for this order (check applicable): Patient decision Surrogate / Agent decision Medical determination that CPR would be ineffective or not in patient's best interest

Physician Signature:    Date Signed:

Witness

Witness Printed Name:

Witness Signature:    Date:

Administrative Use

Order entered into the medical record by:    Date/Time:

By signing below the patient or legally authorized representative affirms that the information above is accurate to the best of their knowledge, that the content and consequences of this DNR order were explained, and that they understand the right to revoke or modify this order in accordance with applicable law.

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