At Speedy Template, You can download Louisiana Do Not Resuscitate Form . There are a few ways to find the forms or templates you need. You can choose forms in your state, use search feature to find the related forms. At the end of each page, there is "Download" button for the forms you are looking form if the forms don't display properly on the page, the Word or Excel or PDF files should give you a better reivew of the page.
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
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.
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
____ 2.LIMIT RESUSCITATION TO: (Specify)_________________________________________________
Speedy Template provides all kinds of legal templates, forms and waivers in different editable formats. Use the template search on the top to find the customized templates that fit your needs with absolutely no cost. Those templates are collected online so we do not claim the ownership of those templates. You can think this website as a legal document search portal and use it to find the printable templates and download them to your local computers and make appropriate adjustments from your end. There is no need to create an account or provide your credit card information. Feel free to download those Word, Excel, PowerPoint or PDF files while we continue to improve this website. Hope you can find those free printable templates useful for business or personal purposes.