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Pennsylvania Do Not Resuscitate Form

This is a sample Out-Of-Hospital DNR Order provided by Pennsylvania Department of Health.

Pennsylvania Do Not Resuscitate Form
Pennsylvania Do Not Resuscitate Form
JANUARY 2007
1. Patient’s Name:______________________________________________________
2A. Attending Physician Statement:
I, the undersigned, state that I am the attending physician of the patient named above. The above-named patient, or the
patient’s surrogate or other person by virtue of that person’s legal relationship to the patient, has requested this order, and I
have made a determination that this patient is eligible for an order and satisfies one of the following: (1) the patient has an
end-stage medical condition; (2) the patient is in a terminal condition; (3) the patient is permanently unconscious and has a
living will directing that no cardiopulmonary resuscitation be provided to the patient in the event of the patient’s cardiac or
respiratory arrest; or (4) the patient is permanently unconscious and has a living will authorizing the surrogate or other person
named below to request an out-of-hospital do-not-resuscitate order for the patient. I direct any and all emergency medical
services personnel, commencing on the date of my signature below, to withhold cardiopulmonary resuscitation, (cardiac
compression, invasive airway techniques, artificial ventilation, defibrillation and other related procedures) from the patient in
the event of the patient’s respiratory or cardiac arrest. If the patient is not yet in cardiac or respiratory arrest, I further direct
such personnel to provide to the patient other medical interventions, such as intravenous fluids, oxygen or other therapies
necessary to provide comfort, care or to alleviate pain, unless directed otherwise by the patient or the emergency medical
services provider’s authorized medical command physician.
Signature of Physician:________________________________Printed:__________________________________________
Date: _______________________ Emergency Telephone Number:______________________________________
Bracelet issued: _____Yes _____No Necklace issued: _____Yes _____No
2B. Attending Physician Statement for Patient Pregnant When Order Issues (in addition to above statement):
I, the undersigned, certify that an obstetrician has examined the patient named above and that the obstetrician and I have
certified in the patient’s medical record as required by law that life-sustaining treatment, nutrition, hydration and
cardiopulmonary resuscitation will have one of the following consequences if provided to this pregnant patient: (1) they will
not maintain the pregnant patient in such a way as to permit the continuing development and live birth of the unborn child; or
(2) they will be physically harmful to the pregnant patient; or (3) they will cause pain to the pregnant patient which cannot be
alleviated by medication.
Signature of Physician:________________________________Printed:__________________________________________
Date:___________________________
3A. Patient’s Statement:
I, the undersigned, hereby direct that in the event of my cardiac and/or respiratory arrest efforts at cardiopulmonary
resuscitation not be initiated and that they may be withdrawn if initiated. I understand that I may revoke these directions at
any time by giving verbal instructions to the emergency medical services providers, by physical cancellation or destruction of
this form or my bracelet or necklace or by simply not displaying this form or the bracelet or the necklace for my EMS
caregivers.
Date___________________________ __________________________________________________
Signature of Patient
(If patient qualified to sign)
3B. Surrogate’s/Other Person’s (by virtue of relationship to patient) Statement:
I, the undersigned, hereby certify that I am legally authorized to execute this order on the patient’s behalf by virtue of having
been designated as the patient’s surrogate and/or by virtue of my relationship to the patient (specify relationship:
_______________). I hereby direct that in the event of the patient’s cardiac and/or respiratory arrest, efforts at
cardiopulmonary resuscitation not be initiated and be withdrawn if initiated.
Date___________________________ __________________________________________________
Signature of Surrogate/Other Person by Virtue of Relationship to Patient
(If patient not qualified to sign)
OUT-OF-HOSPITAL DO-NOT-RESUSCITATE ORDER
Pennsylvania Do Not Resuscitate Form
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