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Louisiana Do Not Resuscitate Form


Louisiana Do Not Resuscitate Form
Louisiana Do Not Resuscitate Form
Louisiana State University Health Care Services Division
Medical Center of Louisiana at New Orleans
DO NOT RESUSCITATE (DNR) AND LIMITATION OF
LIFE SUSTAINING THERAPIES WORKSHEET
I. PURPOSE
Do Not Resuscitate (DNR) orders and Limited Therapy orders shall be considered when life sustaining therapies
are medically or ethically contraindicated. Medical and ethical contraindications to life sustaining therapies are
summarized on the reverse of this worksheet and can be further reviewed in MCL Policy 5021- Limitation of Life
Sustaining Therapies Including Resuscitation. In such circumstances, the following format for limiting therapies is
recommended. Alternative approaches may be acceptable under appropriate circumstances. Patients with advance
directives shall be treated in accordance with MCL Policy 0024 - Advance Directives at the Medical Center of
Louisiana. Please refer to MCL Policy 5011 - Organ and Tissue Donation Program Including Procedures Regarding
Donation After Cardiac Death for brain death criteria and criteria to be a potential donor after cardiac death.
II. POLICY
All patients at MCL will be provided full resuscitation and intensity of care unless otherwise indicated by the
attending staff physician. Therapies which are medically indicated, alleviate pain and suffering, or which support
the personal dignity of the patient will be provided unless refused by a competent patient.
III. DNR AND LIMITED THERAPY OPTIONS (Check those that apply)
Limitation of resuscitation and care orders must be written, signed and dated on the physician’s order sheet. The
medical or ethical contradiction(s) to therapy must be documented in Section IV of this form. Withdrawal of
treatment is not ethically different from withholding of treatment.
____ 1. “DO NOT RESUSCITATE” - No cardiopulmonary resuscitation, no intubation, no defibrillation, no life
sustaining drugs.
____ 2. LIMIT RESUSCITATION TO: (Specify) _________________________________________________
___________________________________________________________________________________
____ 3. LIMITATIONS OF OTHER THERAPIES (Specify) _________________________________________
___________________________________________________________________________________
e.g. “no ICU, no surgery, no antibiotics”, etc.
____ 4. This patient has executed an Advance Directive (Refer to MCL Policy 0024 - Advance Directives at the
Medical Center of Louisiana for more information)
5. Other: (Specify) ______________________________________________________________________
IV. MEDICAL AND/OR ETHICAL CONTRAINDICATORS (This section must be completed)
The medical and/or ethical contraindication to life sustaining therapies in this patient are:
____________________________________________________________________________________________
____________________________________________________________________________________________
The indication(s) for limiting or withdrawing therapy shall be documented in the patient’s medical record and
appropriate orders shall be written on the physician’s order sheet.
MCLN 1421 (R 12/07) - Front
Louisiana Do Not Resuscitate Form
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