Home > Legal > Will and Trust Template > Do Not Resuscitate Template > Wisconsin Do Not Resuscitate Form > Wisconsin Do Not Resuscitate Template

Wisconsin Do Not Resuscitate Form


Wisconsin Do Not Resuscitate Form
Wisconsin Do Not Resuscitate Form
BACKGROUND
INFORMATION/INSTRUCTIONS
FOR
COMPLETING
DO NOT
RESUSCITATE
ORDER
BACKGROUND INFORMATION
Cardiopulmonary
resuscitation
(CPR)
is a
procedure employed
after
cardiac arrest
in
which cardiac massage,
drugs,
and
artificial
ventilation
arc
used
to
restore
breathing
and
circulation.
It
is
standard medical practice
to
perform
CPR on all
pei-'>"n
f'ound
to be in
cardiac
or
respiratory
arrest
in the
absence
of
directives
from an
attending physician
to
withhold
such
action
However,
patients
may
legally
and
ethically
decline these
treatments.
The
DNR
order
is
used
to
implement
their
decision
tlv.
1
CPR is not to be
performed.
This decision
to
limit
CPR
rests
with
the
attending physician
and
his/her
qualified
patient.
le;ja
jjuardian,
or
health
care agent
as
described
in
Chapter
154,
Subchapter
III
of
the
Wisconsin Statutes.
A
qualified
patient
mea:;
a
person
who is at
least
18
years
old and to
whom
any of the
following
conditions applies:
I
The
person
has a
terminal condition.
2.
The
person
has a
medical condition
such
that,
were
the
person
to
suffer
cardiac
or
pulmonary
failure,
resuscitation
would
be
unsuccessful
in
restoring cardiac
or
respiratory
function
or
the
person would
experience
repeated cardiac
or
pulmonar\
failure
within
a
short period before death occurs.
.-
The
person
has a
medical condition such
that,
were
the
person
to
suffer
cardiac
or
pulmonary
failure,
resuscitation
of
;h,r
person would cause
significant
physical pain
or
harm
thai
would outweigh
the
possibility that
resuscitation
would
successfully
restore cardiac
or
respiratory
function
for an
indefinite
period
of
time.
The
bracelet
is
intended
to
communicate
the
existence
of
a
"
Do Not
Resuscitate"
order
to the
emergency
medical
personnel
who may be
summoned
in the
event
of an
emergency.
In
addition,
it
provides guidelines
for
comfort
and
supportive
care
sho'
1
of CPR
that
may be
administered
by
emergency
personnel.
GUIDELINES
FOR
FORM
COMPLETION,
AFFIXING
PLASTIC
BRACELET,
ORDERING
METAL
BRACKLF.T.
A
tier
discussing treatment options
the
patient
or the
legal guardian
or
health
care agent
of the
incapacitated patient,
complete
1
the
DNR
order.
The
types
of
care
to
be
rendered
and
withhold
should
be
carefully
explained
to the
patient,
legal
guardian
or
health
care agent,
and
family
members
by the
attending
physician
or the
attending physician's designee before
the
form
is
'
signed.
After
the
form
is
completed
and
signed,
the
attending
physician
or
designee shall either
affix
the Do Not
Resuscitate
plastic
bracelet
to the
patient's wrist
or
order
a
metal bracelet
from
MedicAlert.
This
decision must
be
documented
in
the
patient's
medical
record.
It
is
recommended that
this
documentation include:
!
The
rationale
for the
decision including
qualifying
medical
condition.
2
The
presence
or
absence
of
decision making capacity
on
the
part
of the
patient.
Two
dated signatures
are
required
for
this
document
to be
valid
and its
intent
carried
out.
I
Patient,
legal
guardian,
or
health
care
agent's signature
and
date
signed.
2.
Attending Physician's signature
and
date signed
by
physiciap.
,
The
metal'
bracelet includes
an
emblem
that
displays
an
internationally
recognized symbol
Staff
of
Aesculapius along
wuh
MedicAlert
on the
front
and the
words
"Wisconsin
Do-Not-Resuscitate-EMS,
and the
qualified patient's
first
and
last
name
on
the
back.
WI DNR
residents
may
provide MedicAlert with other important health information
to be
engraved
on
thfe
b«(ck
of
the
bracelet
at the
time
of
ordering.
To
order
a
metal bracelet
you
need
to
include:
1
Copy
of WI DNR
form signed
by the
attending physician
and
the
patient,
legal guardian,
or
health
care
agem.
2
MedicAlert
DNR
brochure with clear information
and
address
for
mailing
the
bracelet.
."«.
Send payment
to
MedicAlert,
WI
DNR,
2323
Colorado
Avc,
Turlock,
Ca.
95382.
The
patient
should
receive
a
copy
of the DNR
Order Form.
An
original
signed form
or a
legible photocopy
or
electronu
facsimile
is
presumed
to be
valid.
REVOKING
THE DNR
ORDER
The
patient,
legal guardian
or
health
care
agent
can
revoke
the DNR
order
by any of the
following methods:
I
The
patient,
legal
guardian
or
health
care
agent
expresses
to
emergency personnel
the
desire
that
the
patient
be
rcsirscMai-.-.-.
2.
The
patient,
legal
guardian,
or
health care agent
defaces,
burns, cuts
or
otherwise
destroys
the DNR
bracelet.
;
The
patient,
legal guardian,
or
health
care
agent
removes
the DNR
bracelet
or
another
person,
aj^lhe
request
ol
the
IMIV"
legal
guardian,
or
health
care agent
removes
the DNR
bracete-*'
e
DNR
order (and
copies)
should
bt
torn
up and the
patient's
attending
physician
should
be
notified
of
the
revocation.
Utm
the
icnt.
leaal
guardian,
or
health
care agent
may
revoke
an
order issued
under
Chapter
I 54
Wisconsin Status.
The DNR
ordc:
<
IT
revoked when
an
ambulance
is
called. Ambulance personnel
will
honor
the DNR and
will
provide comfort care
only.
Wisconsin Do Not Resuscitate Form
Previous

1/2

Next