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Fillable Form DNR (Do Not Resuscitate)

A DNR or Do Not Resuscitate Form is an order that a person doesn't want to receive cardiopulmonary resuscitation if that person's heart stops beating and allow natural death.


What is a Do Not Resuscitate Form?

A Do Not Resuscitate Form is used by terminally ill individuals who do not want to be saved or brought back to life via Cardiopulmonary Resuscitation (CPR), defibrillation, or other life-saving or life-sustaining medical procedures. It is used by elderly people and individuals who are suffering from a health condition and do not see a path towards a cured condition. For people who want to stay off life-support in the event of a coma or major injury or illness may also use the form.

By definition, a Do Not Resuscitate order, also known as DNR, no code, or allow natural death, is a legal order in written or verbal form, depending on a country or state, that prevents medical interventions when a person requires life-support or his or heart stops beating.

There are laws that govern resuscitation in every state and they differ from one state to another. In general, the law requires that the patient complete and authorizes the Do Not Resuscitate form by signing it with his or her doctor. In some cases, it should be notarized. Furthermore, witnesses may be required to validate the document.

A doctor or hospital should have a copy of the completed and signed Do Not Resuscitate form of a patient. For patients who ordered a do not resuscitate procedure may consider wearing a medical bracelet or necklace that indicates their decision. Doing so would notify medical responders during an emergency in a non-hospital setting.

Before completing and signing a Do Not Resuscitate document or form, a patient must speak with his doctor or healthcare team about his or her decision. After the talk, the document may be completed in the hospital or a private place where the patient is comfortable and can think coherently. If his or her doctor does not want to follow a patient’s wish, the doctor may transfer him or her to another doctor who will carry the instructions. Nevertheless, when a patient changes his or her mind and requests for life-support or life-saving procedures, he or she may talk to the doctor or healthcare team to withdraw the decision. The family or caregiver of a patient should consistently be informed of all decisions at all times. In addition, all documents that assert the DNR should be destroyed.

Take note that the Do Not Resuscitate document does not cover all medical interventions. It is but a part of a more comprehensive medical care plan. Different medical procedures, such as chemotherapy, the use of drugs, and laboratory tests, may still be conducted. The DNR only relates to CPR when blood flow or breathing stops. CPR procedures may include mouth-to-mouth breathing and pressing on the chest, electric shock to restart the heart, the use of breathing tubes to open the airway, and the use of medicines.

How to Fill Out a Do Not Resuscitate Form?

The legal requirements and content of a Do Not Resuscitate document vary from one state to another, depending on their laws. Nevertheless, A DNR document is typically just a one-page file that is easy to prepare and execute. It may be included in a patient’s healthcare directives or living will, which restricts a patient’s right to food, water, and assisted breathing in a terminally ill state.

For your convenience, we have a Do Not Resuscitate form that you can fill out, sign, and print. To answer it accurately, you may use the guide below.

Introduce the patient by providing his or her full legal name, as it appears on all medical records on file.

Write a note that confirms the patient’s request to order all medical personnel to abstain from all attempts to resuscitate him or her and allow a natural death. The section must indicate the state the patient lives.

The first section, Patient Request, should clearly define all of the patient’s wishes regarding CPR procedures.

For it to be valid, he or she should sign and date the section. This process can be done in front of witnesses or a notary public.

The second section, Physician Authorization, indicated the approval of the doctor who is in charge of the patient’s health. This section informs all medical personnel that the physician commands to withhold any resuscitative measures.

The doctor must sign, print his name, and put the date on the spaces provided to certify the DNR form.

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