Do Not Resuscitate Order (Page 2 of 3) in pdf

Do Not Resuscitate Order Page 2

B. PATIENT ADVOCATE CONSENT

I authorize that in the event the declarant’s heart and breathing should stop, no

person shall attempt to resuscitate the declarant. I understand the full import of this

order and assume responsibility for its execution.

This order will remain in effect until it is revoked as provided by law.

________________________________________ _______________________

(Patient advocate’s signature)

(Date)

________________________________________

(Type or print patient advocate’s name)

C. GUARDIAN CONSENT

I authorize that in the event the ward’s heart and breathing should stop, no person

shall attempt to resuscitate the ward. I understand the full import of this order and

assume responsibility for its execution.

This order will remain in effect until it is revoked as provided by law.

________________________________________ _______________________

(Guardian’s signature)

(Date)

_______________________________________

(Type or print guardian’s name)

Do Not Resuscitate Order Page 2