Oklahoma Do-Not-Resuscitate (Dnr) Consent Form (Page 2 of 2) in pdf

Oklahoma Do-Not-Resuscitate (Dnr) Consent Form Page 2

CERTIFICATION 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.

Oklahoma Do-Not-Resuscitate (Dnr) Consent Form Page 2