Do Not Resusitate Papers
States that statutorily authorize Do Not Resuscitate orders REQUIRE a signature from a medical doctor. Several Christian Science Nurses have found that these forms, signed by the Patient and accompanied with a Christian Science oriented Advance Health Care Directive, have been honored by emergency medical personnel from attempting resuscitation of a Patient who has passed away in the home.
NOTE:
Regarding Christian Scientists who want to have a DNR on hand: give a copy to a family member and post one copy in an envelope on the refrigerator or any other readily available place for easy access. It would also be advisable to have an Advance Health Care Directive available with the DNR.
The following information is from a State website and is set forth herein for illustration purposes only
[Consult with your own personal legal adviser regarding your State’s requirements]:
DO NOT RESUSCITATE (DNR)
IMPORTANT INFORMATION
The following instructions provides important information about the types of Do Not Resuscitate (DNR)
requests that will be honored in the field by paramedics, and emergency medical technicians (EMTs) and
hospital physicians and medical staff.
The Do Not Resuscitate (DNR) Form has been developed for the purpose of informing and instructing
paramedics, EMS, hospital physicians and medical staff to forego any resuscitation attempts in the event of
a patients or Declarant’s cardiopulmonary or respiratory arrest. Resuscitative measures that will be withheld
shall include chest compressions, assisted ventilation, endotracheal intubation, defibrillation, and
cardiotonic drugs. However, this form shall not affect the provision of other emergency medical care,
including palliative (pain relief) treatment for pain, dyspnea (labored breathing), major hemorrhage, or
other medical conditions.
The Do Not Resuscitate (DNR) Form must be signed by the patient (“Declarant”) or by an appropriate
guardian/surrogate decision-maker in the event that the Declarant is unable to make or communicate
informed health care decisions. The guardian/surrogate should be the patient’s legal representative (e.g.
spouse, parent, other family member, Durable Power of Attorney, or a court appointed conservator) if one
exists. The patient’s physician must also sign the form, affirming that the patient/surrogate has given
consent to the DNR instruction.
Once paperwork is completed and signed by all required parties, three copies of the form should be
disbursed as follows:
- One copy of the form should be retained by the patient, as resuscitation attempts may be initiated until such
time as a copy of the DNR Form or medallion is presented and the identity of the patient is confirmed. - A second copy of the form should be retained by the physician and made part of the patient’s permanent
medical records. - Finally, a third copy may be used by the patient to order an optional wrist or neck medallion inscribed with
the words “DO NOT RESUSCITATE – EMS.”
In the event that a decision is made to revoke the DNR, the patient should immediately notify their
physician and all copies of the existing DNR form should be destroyed, including any copies which may be
on file with the Medic Alert Foundation or other EMS Authority approved supplier. Medallions and
associated wallet cards should also be destroyed or returned to the supplier. END
HERE IS A SAMPLE DNR:
DO NOT RESUSCITATE (DNR)
By way of a discussion with my health care physician, and after thorough consideration of the
implications of this Agreement, I, ________________________________ hereby request and make it known that in the event should my heart or my breathing cease, no person nor medical procedure shall be initiated or attempted to restart or resuscitate breathing or heart function.
This order shall remain in effect unless otherwise revoked solely by my written request.
I understand that this decision shall not prevent me from receiving other emergency medical care by prehospital
emergency medical care personnel and/or medical care directed by a physical.
I give permission for this information to be given to the hospital emergency care personnel, doctors, nurses,
or other health personnel as deemed necessary to implement this directive.
Being of sound mind, I voluntarily execute this order with full and complete understanding. Therefore, I
hereby agree to the “Do Not Resuscitate Order” (DNR) order.
______________________________________________Declarant/Guardian Signature __________________________________Date
PHYSICIAN ACKNOWLEDGEMENT
I affirm that this Declarant/Guardian is making an informed decision and that this directive is the expressed
wish of the Declarant/Guardian. A copy of this form is in the Declarant’s permanent medical record.
In the event of cardiac or respiratory arrest, no chest compressions, assisted ventilation, intubation,
defibrillation, or cardiotonic medications are to be initiated.
______________________________________________Physician Signature __________________________________Date
ATTESTATION OF WITNESSES
The Declarant executing this order appears to be of sound mind and under no duress, fraud, or undue
influence. I attest that I am of the age of consent (18 years or older) and that I have witnessed the giving of
consent by the above Declarant.
______________________________________ Date ________________________
(First Witness Signature)
______________________________________
(First Witness Printed Name)
________________________________________________ Date __________________________________ (Second Witness Signature)
________________________________________________
(Second Witness Printed Name)