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Alabama Do Not Resuscitate Form

The Alabama do not resuscitate form is provided by Alabama Emergency Medical Services.

Alabama Do Not Resuscitate Form
Alabama Do Not Resuscitate Form
ALABAMA
Emergency Medical Services
Do Not Attempt Resuscitation Order
Patient’s Full Name __________________________________________________________________________________________
Attending/Treating Physician’s Order
I, the undersigned, a physician licensed in Alabama, state that I am the attending physician; or a physician providing
treatment to the patient named above. It is my determination that [must check 1 or 2, below]:
o 1. The patient is an adult (eighteen years of age or older) and IS capable of making an informed decision and of
granting consent about providing, withholding, or withdrawing specific medical treatment or course of
treatment, and the patient has decided that he or she does not wish to be provided resuscitative measures in
the prehospital setting. (Signature of patient required on reverse side).
o 2. The patient is an adult (eighteen years of age or older) and is NOT capable of making an informed decision and
of granting consent about providing, withholding, or withdrawing specific medical treatment or course of
treatment, because the patient is not able to understand the nature, extent, or probable consequences of the
proposed medical decision, or to make a rational evaluation of the risks and benefits of alternatives to that
decision. I have made this determination after consultation with a second physician licensed in Alabama.
If 2, above, is checked (patient if NOT CAPABLE of making an informed decision), then either A, B, or C, below, must
also be checked.
o A. The patient, while still competent, executed a written advance directive which directed that resuscitative
measures be withheld or withdrawn under the present circumstances. (Signature of next of kin required on
reverse.)
o B. The patient appointed a surrogate or attorney-in-fact with authority to direct that resuscitative measures be
withheld or withdrawn under the present circumstances, and the surrogate or attorney-in-fact has so directed.
(Signature of surrogate or attorney-in-fact required on reverse).
o C. The patient has not executed a written advance directive, nor has he or she appointed a surrogate or attorney-
in-fact, but either a court appointed guardian with authority to make such decisions, or a court of competent
jurisdiction has directed that resuscitative measures to be withheld under the present circumstances.
(Signature of guardian required on reverse side, or certified copy of court order must be attached hereto.)
Based on the foregoing, I hereby direct any and all emergency medical services personnel, commencing on the date
below
, to withhold resuscitative measures, i.e., cardiopulmonary resuscitation, cardiac, compression, endotracheal
intubation and other advanced airway management, artificial ventilation, cardiac resuscitative medications, and
cardiac defibrillation, in the event of the patient’s cardiac or respiratory arrest. I further direct such personnel to
provide all reasonable comfort care such as intravenous fluids, oxygen, suction, control of bleeding, administration
of pain medication (if personnel are properly authorized), and other therapies to provide comfort and alleviate pain,
and to provide support to the patient, family members, friends, and others present.
_______________________________________________________________ _________________________________________
Signature of Attending/Treating Physician Date
_______________________________________________________________
_________________________________________
Printed Name Telephone Number (Emergencies)
_______________________________________________________________ _________________________________________
Signature of Second (Consulting) Physician Date
_______________________________________________________________
_________________________________________
Printed Name Telephone Number (Emergencies)
If the patient should die at home while EMS is present or during transport by EMS Personnel, The EMS Provider
shall document such in the narrative portion of the EMS Run Report.
Alabama Do Not Resuscitate Form
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