Do Not Resuscitate Or Intubate Request Form-Oh - Wellsbrooke
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1Do Not Resuscitate / Do Not Intubate Request
Advance Request by the Patient to Limit the Scope of Emergency Medical Care
Do Not Resuscitate (DNR) - In the event of an acute cardiac or respiratory arrest, no cardiopulmonary resuscitation
shall be initiated.
Do Not Intubate (DNI) - In the event of acute or impending respiratory failure, endotracheal intubation to provide sus-
tained assisted ventilation shall not be preformed. DNI does not prohibit emergency management to prevent or reverse
acute airway obstruction with oral, nasal or esophageal obturator airways or treatment of transient respiratory insufficiency
with oxygen or short trials of assisted ventilation with positive pressure ventilation equipment or Ambu-bags.
•
I, ____________________________________________, request limited emergency care as herein described.
•
I understand DNR means that if my heart stops beating or if I stop breathing, NO medical treatment will be
started or continued and I may die as a result.
•
I understand that DNI means that if I stop breathing, I will NOT be placed on an artificial breathing machine and
that I may die as a result.
•
I understand that either or both of these decisions will NOT prevent me from obtaining emergency medical care
by paramedic(s) and receiving other medical care prior to my death at the direction of my physician.
•
I understand that I may revoke these directives at any time.
•
I give permission for this information to be provided to paramedics, physicians, nurses or any other health care
personnel, as necessary, to implement these directives.
_________________________(initial)
I hereby agree to the “Do Not Resuscitate” order.
_________________________(initial)
I hereby agree to the “Do Not Intubate” order.
_________________________________________________________________________________________________
Patient/Authorized Representative Signature
Date
If signed by authorized representative of the patient, please complete the following:
_________________________________________________________________________________________________
Print Name
Relationship
Phone
_________________________________________________________________________________________________
Witness Signature
Date
_________________________________________________________________________________________________
Physician Signature
Phone
Date
830 W. South Boundary, Suite C • Perrysburg, OH 43551 • Phone: 419.931.9930 • Fax: 419.931.9931
White Copy - Office Yellow Copy - Patient
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