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Iowa Do Not Resuscitate Form

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Iowa Do Not Resuscitate Form
Iowa Do Not Resuscitate Form
Iowa Department of Public Health
(Please type or print)
Date of Order: _____/_____/_____
Patient Information:
Name: (Last)____________________(First)____________________(Middle)__________________
Address: _____________________________(City)___________________(Zip)____________
Date of Birth: _____/_____/_____ Gender (Circle): M or F
Name of Hospice or Care Facility (if applicable):
As the attending physician for the above-named patient, I certify that this individual is over 18
years of age and has a terminal diagnosis. After consultation with this patient (or the patient’s legal
representative), I hereby direct any and all health care providers, including qualied emergency
medical services (EMS) personnel, to withhold or withdraw the following life-sustaining procedures in
accordance with Iowa law (Iowa Code chapter 144A):
Cardiopulmonary Resuscitation/Cardiac Compression (Chest Compressions).
Endotracheal Intubation/Articial or Mechanical Ventilation (Advance Airway Management).
Debrillation and Related Procedures.
Use of Resuscitation Drugs.
This directive does NOT apply to other medical interventions for comfort care.
Signature of Attending Physician (MD, DO)
rintedName of Attending Physician Physician’s Telephone (Emergency)
To the extent that it is possible, a person designated by the patient may revoke this order on the
patient’s behalf. If the patient wishes to authorize any other person(s) to revoke this order, the
patient MUSTlist those persons’ names below:
Patientspleasenote: Directions for obtaining a uniform identier are listed on the back of this form. The
uniform identier is the key way the health care provider and/or EMS personnel can quickly recognize
that you have an Out-of-Hospital Do-Not-Resuscitate order. If you are not wearing an identier, the
health care provider and/or EMS personnel may not realize that you do not want to be resuscitated.
hysicianspleasenote: Information regarding the completion of an Out-of-Hospital
Do-Not-Resuscitate order is on the back of this form.
Iowa Do Not Resuscitate Form