Uniform Do-Not-Resuscitate (Dnr) Advance Directive
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2DO-NOT-RESUSCITATE • DNR • DO-NOT-RESUSCITATE • DNR • DO-NOT-RESUSCITATE • DNR
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Illinois Department of Public Health
UNIFORM DO-NOT-RESUSCITATE (DNR) ADVANCE DIRECTIVE
Patient Directive
I, _____________________________, born on ____________, hereby direct the following in the event of:
(print full name)
(birth date)
1. FULL CARDIOPULMONARY ARREST
(When both breathing and heartbeat stop):
x
Do Not Attempt Cardiopulmonary Resuscitation (CPR)
K
(Measures to promote patient comfort and dignity will be provided.)
2. PRE-ARREST EMERGENCY
(When breathing is labored or stopped, and heart is still beating):
SELECT ONE
Do Attempt Cardiopulmonary Resuscitation (CPR) -OR-
K
Do Not Attempt Cardiopulmonary Resuscitation (CPR)
K
(Measures to promote patient comfort and dignity will be provided.)
Other Instructions __________________________________________________________________
__________________________________________________________________________________
Patient Directive Authorization and Consent to DNR Order
(Required to be a valid DNR Order)
I understand and authorize the above Patient Directive, and consent to a physician DNR Order implement-
ing this Patient Directive.
________________________________________
________________________________________
________________
Printed name of individual
Signature of individual
Date
-OR-
________________________________________
________________________________________
________________
Printed name of (circle appropriate title):
Signature of legal representative
Date
legal guardian
OR agent under health care power of attorney
OR healthcare surrogate decision maker
Witness to Consent
(Required to have a witness to be a valid DNR Order)
I am 18 years of age or older and acknowledge the above person has had an opportunity to read this form
and have witnessed the giving of consent by the above person or the above person has acknowledged his/her
signature or mark on this form in my presence.
________________________________________
________________________________________
________________
Printed name of witness
Signature of witness
Date
Physician Signature
(Required to be a valid DNR Order)
I hereby execute this DNR Order on
.
_____________________
Today’s date
________________________________________
________________________________________
___________________________
Signature of attending physician
Printed Name of attending physician
Physician’s telephone number
N Send this form or a copy of both sides with the individual upon transfer or discharge. N
DNR • DO-NOT-RESUSCITATE • DNR • DO-NOT-RESUSCITATE • DNR • DO-NOT-RESUSCITATE
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