Fill and Sign the Nevada Patient Information on Advance Directives Dhcfp State of

DO NOT RESUSCITATE I, , being of sound mind request and grant permission to any and all medical professionals to refrain from resuscitating me in the event that any of the conditions describe herein shall occur. I understand that “Do not resuscitate” (hereinafter referred to as “DNR”) is defined to mean that in the event that my heart should stop beating, or if I should stop breathi ng, no medical procedure shall be instituted to restart breathing or to cause my heart t o start functioning again. I understand that this directive may be revoked by me at any time by destroying this form by any means needed to effectuate the desired result. No one other than myself can revoke this directive. I grant permission for this form to be given to all emergency care personnel should I become incapacitated or require any type of medical care whatsoever. I hereby agree to the “DO NOT RESUSCITATE” (DNR) order. ________________________________ __________________ Patient/Surrogate Signature Date ________________________________ Surrogate’s Relationship to Patient I affirm that the following patient/surrogate is lucid and is making an informed decision and that this directive is the expressed desire of this pati ent. A copy of this form shall be placed in the patient’s medical records and shall rem ain there as evidence of the aforementioned patient’s wishes until such time as he/she may de cide to revoke the signed DNR. In the event of cardiac or respiratory arrest, no chest compression, assisted ventilations, intubations, defibrillation, or cadiotonic medications are to be initiated. ________________________________ __________________ Physician’s Signature Date __________________ Printed Name Telephone Number Address