Maine Health Care Advance Directive Form Page 14
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14DO-NOT-RESUSCITATE (DNR) DIRECTIVE
This section is optional. If you do not want ambulance crews to revive you if your heart or breathing
stops, you and your physician (or nurse practitioner or physician assistant) must complete and sign this
form.
FOR PATIENT TO COMPLETE after consultation with his or her health care provider:
In the event that my heart or breathing stops and I am unable to speak for myself, I, ___________________
(printed name)direct that no efforts be taken to restart my heart or breathing and that Emergency
Medical Services (ambulance crews) if notified, honor my directive. I have come to this decision after
considering my condition and prognosis and the potential risks, burdens and benefits of refusing efforts to
restart my heart or breathing.
I understand that I may change my mind at any time by destroying this form and removing any Maine
EMS approved Do-Not-Resuscitate jewelry, such as MedicAlert. I will also tell my physician (or nurse
practitioner or physician assistant) and other caregivers if I change my mind.
I understand that this form is not valid until my physician (or nurse practitioner or physician assistant)
and I have signed it.
I understand that in a hospital, nursing home, hospice or home health setting, federal law requires that
my physician must include a specific DNR order in my medical record or plan of care, even if we have
both signed this form.
OR
No expiration date
Expires on _______________________________________
____________________________________________________
________________________
Patient Signature
Date Signed
FOR PHYSICIAN, PHYSICIAN ASSISTANT OR NURSE PRACTITIONER TO COMPLETE:
By my signature I affirm that:
(i) After meeting with this patient and discussing this decision, I am satisfied that the patient understands
the potential risks, burdens and benefits of refusing resuscitative interventions in light of the patient’s
medical condition; and (ii) I believe that the patient has made a voluntary informed decision about
resuscitation and I agree to comply with that decision. I will tell any health care providers providing
care under my authority to comply with this decision.
________________________________________
________________________________________
Signature and license level (MD, DO, PA or NP)
Date Signed
________________________________________
________________________________________
Printed Name
Telephone Number
THIS FORM IS ENDORSED BY MAINE EMERGENCY MEDICAL SERVICES
Page 14 of 14
Revised February 2008
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