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Indiana Do Not Resuscitate Form


Indiana Do Not Resuscitate Form
Indiana Do Not Resuscitate Form
STATE OF INDIANA
OUT OF HOSPITAL DO NOT RESUSCITATE DECLARATION AND ORDER
State Form 49559 (R / 9-11)
OUT OF HOSPITAL DO NOT RESUSCITATE DECLARATION
Declaration made this _____________ day of _______________________________, ____________, being of sound mind and at least
eighteen (18) years of age, willfully and voluntarily make known my desires that my dying shall not be artificially prolonged under the
circumstances set forth below.
I declare:
My attending physician has certified that I am a qualified person, meaning that I have a terminal condition or a medical condition such
that, if I suffer cardiac or pulmonary failure, resuscitation would be unsuccessful or within a short period I would experience repeated
cardiac or pulmonary failure resulting in death.
I direct that, if I experience cardiac or pulmonary failure in a location other than an acute care hospital, cardiopulmonary resuscitation
procedures be withheld or withdrawn and that I be permitted to die naturally. My medical care may include any medical procedure necessary
to provide me with comfort care or to alleviate pain.
I understand that I may revoke this Out of Hospital Do Not Resuscitate Declaration at any time by a signed and dated writing, by destroying
or canceling this document, or by communicating to health care providers at the scene the desire to revoke this declaration.
I understand the full import of this declaration
Signature of declarant
Printed name of declarant
City and state of residence
The declarant is personally known to me, and I believe the declarant to be of sound mind. I did not sign the declarant's signature above,
for, or at the direction of, the declarant. I am not a parent, spouse, or child of the declarant. I am not entitled to any part of the declarant's
estate or directly financially responsible for the declarant's medical care. I am competent and at least eighteen (18) years of age.
Signature of witness Printed name
Date (month, day, year)Signature of witness Printed name
OUT OF HOSPITAL DO NOT RESUSCITATE ORDER
I, _______________________________________, the attending physician of ______________________________, have certified the
declarant as a qualified person to make an Out Of Hospital Do Not Resuscitate Declaration, and I order health care providers having
actual notice of this Out Of Hospital Do Not Resuscitate Declaration and Order not to initiate or continue cardiopulmonary resuscitation
procedures on behalf of the declarant, unless the Out Of Hospital Do Not Resuscitate Declaration is revoked.
Signature of attending physician
Printed name of attending physician Medical license number
This declaration and order is effective on the date of execution and remains in effect until the death of the declarant or revocation.
Date (month, day, year)
Date (month, day, year)
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Indiana Do Not Resuscitate Form