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Cardiopulmonary Resuscitation (CPR)
Cardiopulmonary resuscitation (CPR) is a treatment used to attempt to restore heart rhythm and
breathing when they have stopped. It may include chest compressions (forceful pushing on the chest
to make the blood circulate), medicines, electrical shocks, a breathing tube and a hospital stay.
I understand that:
CPR can save a life but it does not always work
CPR does not work as well for people who have chronic (long-term) diseases
recovery from CPR can be painful and difﬁcult.
Note: Make this choice based on your health today. You can always update your health care directive
as you age or your health changes.
I have initialed the option I prefer for this situation. My choice about CPR is:
I want CPR attempted if my heart or breathing stops in all circumstances.
I want CPR attempted if my heart or breathing stops except when my health care provider
has determined that I have little or no reasonable chance of survival even with CPR.
I do not want CPR attempted if my heart or breathing stops. I prefer a natural death.
If I choose this option, I should talk with my health care provider.
Treatments to Extend My Life
If my health care providers determine I am in a vegetative state, or that I have a permanent brain
injury that means it is very likely I will not regain consciousness or recover my ability to know who
I am, I choose the following.
Note: Make this choice based on your health in the future. You can always update your health care
directive as you age or your health changes.
I have initialed the option I prefer for this situation. My choice is:
I would want to stop or withhold all treatments that are extending my life at this time.
This includes, but is not limited to, tube feedings, IV (intravenous) ﬂuids, respirator/
ventilator (breathing machine), CPR and antibiotics (medicines).
I would want all the treatments recommended by my health care team until they agree
that such treatments are harmful and no longer helpful. This includes, but is not limited to,
tube feedings, IV ﬂuids, respirator/ventilator, CPR and antibiotics.
I would want to receive limited treatment. I would want to receive certain types of care in
certain circumstances, as I’ve written below. For example, you may write that you want to
live on life support until all of your family has arrived.
NAME, DOB, MRN