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Georgia Do Not Resuscitate Form

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Georgia Do Not Resuscitate Form
Georgia Do Not Resuscitate Form
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
indicated reason(s).
________ 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.
_________________ ______________________________________________
Date Primary Physician Signature
_________________ ______________________________________________
Date Concurring Physician Signature
I, the undersigned, do hereby consent and request that no resuscitative measures be initiated upon.
___________________________________ (Resident’s Name) to restore cardiac and/or respiratory functions in,
the event of cardiac/respiratory arrest, and I direct that this be written into the resident’s medical chart. This has
been discussed with the resident’s attending physician, and I understand that this agreement pertains only to the
provision of cardiopulmonary resuscitation (CPR) and not to other life sustaining measures. I also understand that,
although CPR will not be performed in the event of cardiac/respiratory arrest, all efforts will be made to keep the
resident as comfortable as possible.
I further declare that, if the resident is unable to express his/her own wishes in this matter, I am the highest
authorized person who may consent to this “Do Not Resuscitate” agreement in the order or priority listed below:
_____ Person appointed by the Resident under Durable Power of Attorney for Health Care.
_____ Resident’s spouse.
_____ Resident’s legal guardian.
_____ Resident’s son or daughter (18 years of age or older).
_____ Resident’s parent.
_____ Resident’s brother or sister (18 years of age or older).
I have been informed of the provisions of the Georgia law authorizing and regulating order not to resuscitate
certain patients (Chapter 38, Title 31 of the Official Code of Georgia Annotated). I understand that consent for the
order for resuscitation may be revoked at any time by the consenting person.
_________________ ______________________________________________
Date Signature of Resident or Authorized Person
Georgia Do Not Resuscitate Form