"Do Not Resuscitate (DNR) Form"

What Is a DNR Form?

A Do Not Resuscitate (DNR) Form is a medical document that is signed by doctors and used within medical organizations when it comes to deciding whether a patient needs to have cardiopulmonary resuscitation (CPR) or not. The purpose of the document is to inform health care providers not to do CPR for the patient if their heart stops beating.

Alternate Names:

  • Do Not Resuscitate Order Form;
  • DNR Order.

This type of form can be signed by a doctor at the patient's request. Commonly, patients who suffer from chronic or terminal illnesses, or elderly patients, sometimes request this kind of order to make sure the health care providers won't use CPR on them. Each case has its own specifics, but generally, they choose it due to health reasons, religious reasons, family reasons, etc. A DNR Form template can be downloaded through the link below.

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How to Get a DNR Form?

The decision of whether you need a DNR Form or not can be made by your physician. Those patients who would like to get the order usually set an appointment with their doctor and then request the form during this appointment. After you have requested the order, the physician elevates your situation and decides whether or not you should be resuscitated. If they agree with your request, then they provide you with the state's form for such kind of procedure and co-sign them with you.

Once the form is completed and signed, the doctor adds it to your medical records. Then they inform you how to get this document in other forms that you can keep (for example, a wallet card).

Who Can Sign a Do Not Resuscitate Order?

Generally, a DNR Form is supposed to be signed by both the patient and the practitioner. The document itself does not require a lot of writing, nevertheless, it contains an extensive amount of information that the patient must acknowledge:

  1. The Title. The document should start with a title that will define its nature. In this case, the form can be titled "Do Not Resuscitate Order," or "DNR Order." Additionally, individuals can use other shortenings such as DNACPR (Do Not Attempt Cardiopulmonary Resuscitation) or DNAR (Do Not Attempt Resuscitate).
  2. Information About the Patient. In the first part of the document, the patient can state their full name and their residential address.
  3. Information About the Doctor. The doctor that has made a decision about the DNR Order is supposed to state their name and mailing address.
  4. Order's Details. Here, the patient can read all of the statements they agree on by signing this document. These statements designate that the patient requests a DNR Order and that they know what it means, they agree on sending this information to other hospitals, and more.
  5. Signatures. To give the document legal power, the patient and the practitioner must sign it in a presence of a witness.
  6. Witness Information. The witness is required to state that both parties were in sound mind and under no unfair duress during the signing of this document. They also should state their full name, address, and signature on the document.

If, in your situation, the witness is required to sign the order, then before looking for one ask your doctor whether there are any requirements to the witness. Sometimes, the patient's relatives and their healthcare representatives are not allowed to witness due to their involvement in the situation.


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Do Not Resuscitate (DNR) Form
This document represents the official request, legal in the State of __________________,
to order all medical personnel to cease any attempt to resuscitate the Patient and allow a
natural death. Sections 1, 2, 3, or 4 must be completed along with Section 5.
1. Patient Request. I, _____________________________, the undersigned Patient,
direct that resuscitative measures be withheld from me in the event of cardiopulmonary
cessation. I have discussed this decision with my physician, and I understand the
consequences of this decision.
_________________________________
_________________________________
Patient’s Signature
Date
2. Advance Directive/Living Will. I, _____________________________, an Authorized
Representative of _____________________________, hereby attest the Patient is no
longer competent or able to understand, appreciate, and direct their medical treatment
with no hope of regaining that ability.
Therefore, I agree to follow a duly executed Advance Directive/Living Will with health
care instructions specifying that no life-sustaining treatment be provided was previously
authorized by the Patient and has been made part of their medical record.
_________________________________
_________________________________
Representative’s Signature
Date
. Medical Power of Attorney. I, _____________________________, the Agent or
3
Attorney-in-Fact for the Patient as designated by a duly executed Medical Power of
Attorney or equivalent document reserve the right to make decisions regarding the
providing, withholding, or withdrawal of life-sustaining treatment for the Patient.
Therefore, I hereby direct that resuscitative measures be withheld from the Patient in the
event of cardiopulmonary cessation. A copy of the Agent/Attorney-in-Fact designation
(e.g. living will, power of attorney, advance directive, etc.) has been attached and made
part of the Patient’s medical record.
_________________________________
_________________________________
Signature of Agent/Attorney-in-Fact
Date
©
TEMPLATEROLLER.COM
Do Not Resuscitate (DNR) Form
This document represents the official request, legal in the State of __________________,
to order all medical personnel to cease any attempt to resuscitate the Patient and allow a
natural death. Sections 1, 2, 3, or 4 must be completed along with Section 5.
1. Patient Request. I, _____________________________, the undersigned Patient,
direct that resuscitative measures be withheld from me in the event of cardiopulmonary
cessation. I have discussed this decision with my physician, and I understand the
consequences of this decision.
_________________________________
_________________________________
Patient’s Signature
Date
2. Advance Directive/Living Will. I, _____________________________, an Authorized
Representative of _____________________________, hereby attest the Patient is no
longer competent or able to understand, appreciate, and direct their medical treatment
with no hope of regaining that ability.
Therefore, I agree to follow a duly executed Advance Directive/Living Will with health
care instructions specifying that no life-sustaining treatment be provided was previously
authorized by the Patient and has been made part of their medical record.
_________________________________
_________________________________
Representative’s Signature
Date
. Medical Power of Attorney. I, _____________________________, the Agent or
3
Attorney-in-Fact for the Patient as designated by a duly executed Medical Power of
Attorney or equivalent document reserve the right to make decisions regarding the
providing, withholding, or withdrawal of life-sustaining treatment for the Patient.
Therefore, I hereby direct that resuscitative measures be withheld from the Patient in the
event of cardiopulmonary cessation. A copy of the Agent/Attorney-in-Fact designation
(e.g. living will, power of attorney, advance directive, etc.) has been attached and made
part of the Patient’s medical record.
_________________________________
_________________________________
Signature of Agent/Attorney-in-Fact
Date
©
TEMPLATEROLLER.COM
4. Surrogate Consent. I, _____________________________, the Surrogate certified to
make decisions in consultation with the attending physician, regarding the providing,
withholding, withdrawal of life-sustaining treatment for the Patient.
After consultation with the attending physician, I hereby direct that resuscitative
measures be withheld from the Patient in the event of cardiopulmonary cessation. I
believe that this decision conforms as closely as possible to what the Patient would have
wanted.
I make this decision in good faith and without consideration of the financial benefit or
burden which may accrue to me or to the health care provider as a result of this decision.
A copy of the Health Care Surrogate Designation has been attached and made part of the
Patient’s Medical Record.
_________________________________
_________________________________
Surrogate’s Signature
Date
5. Physician Authorization. Based on the aforementioned information, I hereby direct
any and all medical personnel, emergency responders, and paramedical personnel to
withhold resuscitative measures i.e. cardiopulmonary resuscitation, chest compression,
endotracheal intubation and other advanced airway management, artificial ventilation,
cardiac resuscitative medications, and cardiac defibrillation, in the event of
cardiopulmonary cessation in the Patient.
I further direct the implementation of all reasonable comfort care such as oxygen,
suction, control of bleeding, administration of pain medication by personnel so
authorized, and other therapies to provide comfort and alleviate suffering by the Patient,
and to provide support to the Patient, family members, friends, and others present.
_________________________________
_________________________________
Physician’s Signature
Date
6. Witnesses and/or Notary Public. I/We, the undersigned Witness(es), declare that all
signing parties to this document were of sound mind, and under no duress, fraud, or
undue influence.
©
TEMPLATEROLLER.COM
In addition, I/we hereby attest to have witnessed their signatures and have no monetary
gain from the authorization of this form, including but not limited to, being made part of
the Patient’s estate or of a relative that is part of the Patient’s estate.
_________________________________
________________________________
Witness Signature
Witness Signature
_________________________________
_________________________________
Date
Date
Notary Acknowledgment
State of _____________________
County of ___________________
The foregoing was acknowledged before me this ____ day of _________________, by
the undersigned, _________________, who is personally known to me or satisfactorily
proven to me to be the person whose name is subscribed to the within instrument.
_________________________________
Printed Name of Notary Public
_________________________________
Signature of Notary Public
My commission expires: ___________________
(seal)
©
TEMPLATEROLLER.COM
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