Source: https://legaltemplates.net/form/dnr-form/
Timestamp: 2019-11-20 04:42:35
Document Index: 560547575

Matched Legal Cases: ['§ 420', '§ 50', '§ 20', '§ 36', '§ 450', '§ 20', '§ 137', '§ 4780', '§ 10', '§ 15', '§ 7', '§ 19', '§ 2505', '§ 90', '§ 401', '§ 23', '§ 31', '§ 3701', '§ 327', '§ 63', '§ 39', '§ 127', '§ 5484', '§ 16', '§ 23', '§ 144', '§ 44', '§ 65', '§ 44', '§ 311', '§ 68', '§ 40', '§ 5', '§ 5', '§ 54', '§ 333', '§ 70', '§ 16', '§ 41', '§ 154', '§ 190', '§ 35']

Free DNR Form | Do Not Resuscitate Order Forms | PDF & Word Sample
Updated September 25, 2019 | Written by Susan Chai, Esq.
Free DNR Form (Do Not Resuscitate)
Use our attorney-drafted DNR Form to withhold or withdraw from cardiopulmonary resuscitation (CPR) in the event that your heart stops beating or you stop breathing.
Free Do Not Resuscitate Form (PDF & MS Word)
Do Not Resuscitate Form (DNR): What is it?
When is a DNR Appropriate?
Do Not Resuscitate Laws by State
1. Free Do Not Resuscitate Form
(PDF & MS Word)
Printable Do Not Resuscitate Form (MS Word)
The Do Not Resuscitate form PDF below is a sample. It details an order from the patient, ‘Michelle R Kane’, and an affirmation by her physician, ‘William S Bryan,’ that both parties agree to and understand the scope of the DNR form.
2. Do Not Resuscitate Form (DNR): What is it?
A Do Not Resuscitate Form, or DNR Form, is an end-of-life medical directive which instructs health care professionals to withhold life-sustaining treatment at the behest of the patient.
Patients who choose to obtain a DNR order are assured that no resuscitation methods will be performed in the event of a medical emergency.
A DNR form is a specific document governing distinct forms of treatment and as a result there are essentially no differences between the multiple types of DNRs.
DNR forms may be known by the following names, depending on your location:
In addition to a DNR form, the following are important end-of-life and estate planning documents:
Acquire your own personalized DNR form by answering just a few simple questions.
The definition of DNR in a DNR order simply stands for “do not resuscitate”.
If your heart stops beating or you stop breathing, a DNR form restricts emergency medical technicians or hospital personnel from attempting to revive you.
In medical terms, “resuscitate” simply refers to the various procedures used by healthcare professionals in an emergency situation to revive a person from unconsciousness or the brink of death.
In the case of a DNR order, however, “resuscitate” specifically refers to the use of cardiopulmonary resuscitation — commonly referred to as CPR.
Basic CPR techniques involve a series of chest compressions and occasional mouth-to-mouth breathing.
Advanced cardiopulmonary resuscitation (typically performed by EMS responders or trained medical personnel) involves a device known as a defibrillator, or AED. An AED delivers an electrical shock to the patient in order to reestablish a steady rhythm to their heart beat.
As a reference, resuscitation methods may include:
Cardiac compression (or chest compressions)
Defibrillation (electrical shock)
Artificial ventilation (mouth-to-mouth breathing)
Intubation (advanced airway management involving a breathing tube)
A do not resuscitate form instructs medical professionals not to use any form of CPR (basic or advanced), should you become incapacitated and require a life-sustaining procedure.
3. When is a DNR Appropriate?
End-of-life planning can be a difficult subject to address, let alone navigate. But the fact of the matter is, we all must deal with this issue at some stage of our lives. Obtaining your own DNR document should not be taken lightly — as it truly addresses life and death matters.
Scenario #1: Patients / Individuals Diagnosed with a Terminal Condition
For anyone diagnosed with a painful or terminal condition, a DNR form can help avoid prolonged suffering. Making the choice to withdraw resuscitation in the event of a cardiac or respiratory arrest does not preclude that palliative care will be withheld. That is to say, the administration of pain-relieving medication and comfort care will still be offered, should you desire.
Scenario #2: Elderly Individuals
Age is another factor that’s important to keep in mind when debating whether a DNR form is right for you. Resuscitation is an intense and oftentimes traumatic medical procedure which elderly patients may have trouble recovering from should it be successful.
Chest compressions must be applied with extreme force in order to get blood pumping through the heart. Broken ribs, bruised lungs, or even damage to the heart itself are all potential ramifications of successful CPR.
Intubation may also be used if a patient stops breathing. This invasive technique requires a tube to be rapidly inserted into the windpipe of a patient in order to manage airflow. This can lead to minor or severe complications such as damage to the esophagus and other tissue in the throat.
Scenario #3: Religious Values
Contrary to what some may think, signing a do not resuscitate order is not prohibited in the eyes of many religious institutions. With that said, each patient must consider their own personal ethics and religious values before authorizing any end-of-life planning documentation.
What Happens if a DNR is Not Followed?
In 2016, a woman in Santa Fe, New Mexico was admitted to the emergency room of a local hospital. Hospital staff attempted to resuscitate her twice — in direct violation of her do not resuscitate order.
This particular patient suffers from a rare condition which causes her immense pain and requires costly medication. As a result of this condition, she preemptively drafted a DNR form in order to avoid further expense and suffering. The hospital staff ignored her DNR form, and she filed a lawsuit shortly after the ordeal.
Signing a DNR is the same as any other legally-binding document. Once your DNR papers have been approved and filed into your medical records, they must be recognized and followed by any physician that treats you.
Additionally, your family can not override your DNR form against your will. Unless you have authorized someone to act on your behalf as your health care representative (either within the DNR itself or through a medical power of attorney), only you may choose to revoke your DNR form.
4. How to Get a DNR Form
Once you’ve decided to create your own document, there are plenty of ways for you to get a DNR form.
Our DNR form builder handles all of the necessary DNR paperwork for you. Upon completion, take your DNR medical form to your physician and have them sign it. Your doctor should then file it with the rest of your medical records.
In some instances, EMTs arriving on the scene of a medical emergency may not immediately be able to identify you or have access to your medical records on hand. Ask your doctor where you can find an official DNR bracelet which can be on your person at all times — instructing first responders how to proceed.
5. Do Not Resuscitate Laws by State
Nearly every state in America has guidelines governing do not resuscitate orders. These laws ensure patients retain a sense of control over their end-of-life planning.
The following table shows which states require signatures from patients, physicians, witnesses, a notary public, or some combination of each, in order for a DNR form to be legally valid.
Alabama Patient and Physician AL Code § 420-5-19-.02 Montana Patient and 2 Witnesses MT Code § 50-9-103
Alaska Patient and either a Witness, Notary Public, or Physician AK Stat 13.52.150 Nebraska Patient and either a Notary Public or 2 Witnesses NE Code § 20-404
Arizona Patient, Physician, and Witness AZ Rev Stat § 36-3251 Nevada Patient and Attending Physician NV Rev Stat § 450B.520
Arkansas Patient and either a Notary Public or 2 Witnesses AR Code § 20-13-901 New Hampshire Patient and Attending Physician NH Rev Stat § 137-J:26
California Patient and Primary Physician CA Prob Code § 4780 New Jersey Patient and Attending Physician NJ Admin Code § 10:48B
Colorado Patient and Attending Physician CO Rev Stat § 15-18.6-103 New Mexico Patient and Physician NM Stat § 7.27.6.8
Connecticut Patient and Physician CT Gen Stat § 19a-580d New York Patient and Physician NY Public Health Article 29-B
Delaware Patient and 2 Witnesses 16 DE Code § 2505 North Carolina Patient, a Notary Public, and 2 Witnesses NC Gen Stat § 90-321
Florida Patient and Primary Physician FL Stat § 401.45 North Dakota Patient and either a Notary Public or 2 Witnesses ND Cent Code § 23-06.5
Georgia Patient and Attending Physician GA Code § 31-39.6.1 Ohio Patient and Physician OH Admin Code § 3701-62
Hawaii Patient and Attending Physician HI Rev Stat § 327K-2 Oklahoma Patient, Physician, and 2 Witnesses OK Stat § 63-3131.5
Idaho Patient and Physician ID Code § 39-4514 Oregon Patient and 2 Witnesses OR Rev Stat § 127.810
Illinois Patient and Witness 755 ILCS 40/65 Pennsylvania Patient and Attending Physician PA Con Stat Title 20 § 5484
Indiana Patient, Physician, and 2 Witnesses IN Code § 16-36-5 Rhode Island Patient and 2 Witnesses RI Gen Laws § 23-4.11
Iowa Physician IA Code § 144A.7A South Carolina Patient and Physician SC Code § 44-78-10
Kansas Patient and Witness KS Stat § 65-4943 South Dakota Patient and Attending Physician SD Admin Rules § 44:05:06
Kentucky Patient and Primary Physician KY Rev Stat § 311.6225 Tennessee Patient and Physician TN Code § 68-11-224
Louisiana Patient and 2 Witnesses LA Rev Stat § 40:1151.2 Texas Patient and either a Notary Public or 2 Witnesses TX HSC Chapter 166
Maine Patient and 2 Witnesses ME Rev Stat § 5-805 Utah Patient and Physician UT Admin Code § R432-31
Maryland Patient and Physician MD Health-Gen Code § 5-608.1 Vermont Patient and Physician VT Stat Title 18 Chapter 231
Massachusetts Patient and Physician None Virginia Patient and Physician VA Code § 54.1-2987.1
Michigan Patient, Attending Physician, and 2 Witnesses MI Comp Laws § 333.1053 Washington Patient and 2 Witnesses WA Rev Code § 70.245
Minnesota Patient and either a Notary Public or 2 Witnesses MN Stat Chapter 145C West Virginia Patient and Physician WV Code § 16-30
Mississippi Patient and Physician MS Code § 41-41-302 Wisconsin Patient and Physician WI Stat § 154.17
Missouri Patient and Attending Physician MO Rev Stat § 190.600 Wyoming Patient and Physician WY Stat § 35-22-501