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DO NOT RESUSCITATE ORDER
FOR
_______________________
ATTENTION! DO NOT MAKE ANY ATTEMPT TO RESUSCITATE THIS PATIENT!
This document represents the official request, legal in the State of
_______________________, to order all medical personnel to cease any attempt to
resuscitate the Patient and allow a natural death. Section I, II, III, or IV must be
completed along with Section V.
I. Patient Request
I, _______________________, the undersigned Patient, direct that resuscitative
measures be withheld from me in the event of cardiopulmonary cessation. I have
discussed this decision with my physician, and I understand the consequences of this
decision.
Signature of Patient _______________________ Date ____________
Section II. Advance Directive/Living Will
I, _______________________, an Authorized Representative of
_______________________ [Hospital/Medical Facility], hereby attest the Patient is no
longer competent or able to understand, appreciate, and direct their medical treatment
with no hope of regaining that ability. Therefore, I agree to follow a duly executed
Advance Directive/Living Will with health care instructions specifying that no life-
sustaining treatment be provided was previously authorized by the Patient and has
been made part of their medical record.
Signature of Representative _______________________ Date ____________
Section III. Medical Power of Attorney Agent/Attorney-in-Fact Consent
I, _______________________, the Agent/Attorney-in-Fact for the Patient as designated
by a duly executed Medical Power of Attorney or equivalent document reserve the right
to make decisions regarding the providing, withholding, or withdrawal of life-sustaining
treatment for the Patient. Therefore, I hereby direct that resuscitative measures be
withheld from the Patient in the event of cardiopulmonary cessation. A copy of the
Agent/Attorney-in-Fact designation (e.g. living will, power of attorney, advance directive,
etc.) has been attached and made part of the Patient’s medical record.
Signature of Agent/Attorney-in-Fact _______________________ Date ____________
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Section IV. Surrogate Consent
I, _______________________, the Surrogate certified to make decisions in consultation
with the attending physician, regarding the providing, withholding, withdrawal of life-
sustaining treatment for the Patient. After consultation with the attending physician, I
hereby direct that resuscitative measures be withheld from the Patient in the event of
cardiopulmonary cessation. I believe that this decision conforms as closely as possible
to what the Patient would have wanted. I make this decision in good faith and without
consideration of the financial benefit or burden which may accrue to me or to the health
care provider as a result of this decision. A copy of the Health Care Surrogate
Designation has been attached and made part of the Patient’s Medical Record.
Signature of Surrogate _______________________ Date ____________
V. *Physician Authorization
Based on the aforementioned information, I hereby direct any and all medical
personnel, emergency responders, and paramedical personnel to withhold resuscitative
measures i.e. cardiopulmonary resuscitation, chest compression, endotracheal
intubation and other advanced airway management, artificial ventilation, cardiac
resuscitative mediations, and cardiac defibrillation, in the event of cardiopulmonary
cessation in the Patient.
I further direct the implementation of all reasonable comfort care such as oxygen,
suction, control of bleeding, administration of pain medication by personnel so
authorized, and other therapies to provide comfort and alleviate suffering by the Patient;
and to provide support to the Patient, family members, friends, and others present.
Signature of Physician _______________________ Date ____________
Print Name _______________________
*Physician’s authorization is required in all 50 States except Kentucky.
VI. *Witness(es) and/or Notary Public
I/We, the undersigned Witness(es), declare that all signing parties to this document
were of sound mind, and under no duress, fraud, or undue influence. In addition, I
hereby attest to have witnessed their signatures and have no monetary gain from the
authorization of this form, including but not limited to, being made part of the Patient’s
estate or of a relative that is part of the Patient’s estate.
Signature of Witness #1 _______________________ Date ____________
Print Name _______________________
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Signature of Witness #2 _______________________ Date ____________
Print Name _______________________
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Notary Acknowledgment
State of _______________________
County of _______________________
The foregoing instrument was acknowledged before me this ____ day of
_______________________, 20____, by _______________________ (name of person
acknowledged).
_____________________________________
(Signature of Person Taking Acknowledgment)
(Title or Rank): _________________
(Serial Number, if any): _________________
*The following States have additional signature requirements (alphabetical): Arizona (one (1) additional witness),
Illinois (one (1) additional witness), Indiana (two (2) additional witnesses), Kansas (one (1) additional witness),
Kentucky (two (2) additional witnesses or a notary public), Nebraska (one (1) additional witness), Oklahoma (two
(2) additional witnesses), and Texas (two (2) additional witnesses or a second (2
nd
) physician)
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