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Nebraska Dakota Do Not Resuscitate Form

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Nebraska Dakota Do Not Resuscitate Form
Nebraska Dakota Do Not Resuscitate Form
I, _____________________________________ , have been diagnosed as having a medical illness. I have discussed both the
prognosis of this illness and the treatment options with my physician and request that in the event of my
cardiopulmonary arrest, cardiopulmonary resuscitation and/or mechanical ventilations not be initiated.
I give permission for this information to be given to Emergency Medical Service and Mobile Health Care personnel,
physicians, nurses, or other health care personnel as necessary to carry out these wishes. I understand that this order
is valid from this point forward until rescinded by either myself or my designated Durable Power of Attorney for Health
Care, and further agree that a copy of this form is as valid as the original. Incomplete forms may be returned as being
DO NOT INTUBATE I understand that DO NOT INTUBATE means that in the event that my breathing is inadequate
I do not wish a tube placed in my airway to maintain my respirations artificially.
DO NOT RESUSCITATE (DNR) I understand that DNR means that if my heart stops beating, or is inadequate, or that
if I stop breathing or my breathing is inadequate, that no artificial resuscitation will be initiated or continued. I
understand that I will continue to receive supportive medical care as deemed appropriate by health care personnel,
though cardiopulmonary resuscitation will not take place.
_______________________________________________________________________________ _______________________________________________
Patient, or Next of Kin Signature or Guardian of Person or Durable Date
Power of Attorney for Health Care (Attach Appointment form).
________________________________________________________________________________ _______________________________________________
Patient Address (Including facility name if applicable) Witness
I certify that I have discussed his or her medical illness, treatment and prognosis with the patient and that the entry of
this DNR order is appropriate for:
_____________________________________________________ _________________________________________________
Patient Name Date of Birth
_____________________________________________________ _________________________________________________ Date:___/___/___
Printed Physician Name Physician Signature
_____________________________________________________________________________________________________________________ Date: ___/___/___
Agency Completing Form and Signature of Agency Representative (required if “By Telephone Order box below is checked)
By telephone order, the patient’s attending physician referenced above was consulted regarding the DNR status,
however, was unavailable to personally appear to provide an original signature. The agency representative above
verifies the consultation and authorization of the physician as indicated.
Copy Distribution:
*Patient File Home Health/Hospice Agency
Attending Physician Patient’s Home (if applicable)
*Original DNR form must be kept in patient’s primary medical file.
Nebraska Dakota Do Not Resuscitate Form