Form Dnr - Oklahoma Do-Not-Resuscitate Consent - Certification Of Physician Page 3
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3CERTIFICATION OF PHYSICIAN
(This form is to be used by an attending physician only to certify that an incapacitated person
without a representative would not have consented to the administration of cardiopulmonary
resuscitation in the event of cardiac or respiratory arrest. An attending physician of an
incapacitated person without a representative must know by clear and convincing evidence that
the incapacitated person, when competent, decided on the basis of information sufficient to
constitute informed consent that such person would not have consented to the administration of
cardiopulmonary resuscitation in the event of cardiac or respiratory arrest. Clear and convincing
evidence for this purpose shall include oral, written, or other acts of communication between the
patient, when competent, and family members, health care providers, or others close to the
patient with knowledge of the patient's desires.)
I hereby certify, based on clear and convincing evidence presented to me, that I believe that
would not have consented to the Name of Incapacitated Person adminstration of cardiopulmonary
resuscitation in the event of cardiac or respiratory arrest. Therefore, in the event of cardiac or
respiratory arrest, no chest compressions, artificial ventilation, intubations, defibrillation, or
emergency cardiac medications are to be initiated.
_________________________
____________________________
Physician's Signature/Date
Physician's Name (PRINT)
_______________________________________________________________________________
Physician's Address/Phone
Witnesses must be individuals who are eighteen (18) years of age or older who are not legatees,
devisees or heirs at law.
It is the intention of the Legislature that the preferred, but not required, do-not-resuscitate form in
Oklahoma shall be the form set out in subsection B of this section.
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