Out-Of-Hospital Do Not Resuscitate Form (Page 2 of 2) in pdf

Out-Of-Hospital Do Not Resuscitate Form Page 2

ALL PATIENTS HAVE THE RIGHT TO MAKE HEALTHCARE DECISIONS

INCLUDING THE RIGHT TO ACCEPT OR

REFUSE LIFE-SAVING MEDICAL TREATMENT.

ASSESS THE PATIENT FOR THE ABSENCE OF BREATHING

AND/OR HEARTBEAT.

IF THE PATIENT IS NOT IN CARDIAC AND/OR RESPIRATORY

ARREST, PROVIDE ALL NECESSARY CARE, INCLUDING TRANSPORT

IF REQUIRED.

IF THE PATIENT IS IN CARDIAC AND/OR RESPIRATORY ARREST,

DO NOT INITIATE CPR AND RESUSCITATIVE EFFORTS.

FOLLOW LOCAL EMS PROTOCOLS FOR PRONOUNCEMENT.

DOCUMENT ALL PERTINENT INFORMATION ON YOUR RUN

SHEET AND ATTACH A COPY OF THIS OUT-OF-HOSPITAL DNR

ORDER.

ONLY THE INDIVIDUAL(S) (PATIENT, SURROGATE, OR PHYSICIAN)

WHO SIGNED THIS FORM MAY RESCIND IT AT ANY TIME.

PHOTOCOPIES OF THIS DOCUMENT ARE PERMITTED AND

SHALL BE HONORED AT ALL TIMES.

THIS DOCUMENT, ITS INTENT AND ASSOCIATED POLICIES ARE SUPPORTED BY:

Medical Society of New Jersey

New Jersey Department of Health and Senior Services

New Jersey Chapter, American College of Emergency Physicians

New Jersey State Nurses Association

New Jersey HealthDecisions

New Jersey Association of Osteopathic Physicians and Surgeons

Academy of Medicine of New Jersey

New Jersey MICU Program Administrators Association

MICU Advisory Council

New Jersey State First Aid Council

IF THERE ARE ANY QUESTIONS CONCERNING THE TREATMENT

AND/OR PRONOUNCEMENT OF THIS PATIENT, CALL:

CONTACT PERSON:_____________________________TELEPHONE:(

) __________- ________________

AGENCY:____________________________________________________________________________________

Out-Of-Hospital Do Not Resuscitate Form Page 2