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Do Not Resuscitate Form
It has been determined by the undersigned physicians that ______________________________ (Resident’s
name) qualifies as a candidate for non-resuscitation in the event of cardiac/respiratory arrest, for the below
________ The resident has a medical condition which can reasonably be expected to result in the imminent
death of the resident.
________ The resident is in a non-cognitive state with no reasonable possibility of regaining cognitive
________ The resident is a person for whom cardiopulmonary resuscitation would be medically futile in that
such resuscitation will likely be unsuccessful in restoring cardiac and respiratory function or will
only restore cardiac and respiratory function for a brief period of time the so that the resident will
likely experience repeated need for cardiopulmonary resuscitation over a short period of time.
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