Do Not Resuscitate Order

Patient Name:

Date:

I am: ¨ The Patient

¨ Surrogate

¨ Proxy

¨ Power of Attorney

I, being fully informed that a DNR means that resuscitative procedures will not be performed in

the event of cardiac or respiratory arrest, hereby request that CPR be withdrawn or withheld from

the Patient named above. I understand that in these instances only limited emergency care will be

provided.

Patient Name

Date

Physician Name:

Clinic/Hospital:

Date:

I, the Physician, recognize that the Patient or his/her proxy has made an informed decision in

executing this directive. A copy of this DNR order will be kept in the Patient’s permanent medical

file.

In the event of cardiac or respiratory arrest no intubation, defibrillations, chest compressions,

assisted breaths, or cardiotonic medications will be administered to the Patient.

Physician Name

Date

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Parent category: Medical