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The California Do Not Resuscitate (DNR) Order form serves as a crucial document for individuals who wish to communicate their preferences regarding resuscitation efforts in the event of a medical emergency. This form is designed to be completed by patients, often in consultation with healthcare providers, and it outlines the specific wishes of the individual concerning life-sustaining treatments. Key elements of the DNR form include the patient’s name, date of birth, and the signatures of both the patient and a physician. This ensures that the order is legally recognized and can be acted upon by medical personnel. Additionally, the form emphasizes the importance of informed consent, allowing individuals to make decisions that reflect their values and beliefs about end-of-life care. Understanding the implications of a DNR order is essential for patients and their families, as it directly influences the type of medical interventions they may receive in critical situations.
PDF Specifics
| Fact Name | Description |
|---|---|
| Purpose | The California Do Not Resuscitate (DNR) Order form allows individuals to express their wishes regarding resuscitation efforts in the event of a medical emergency. |
| Governing Law | This form is governed by California Health and Safety Code Section 7190-7199, which outlines the legal framework for advance healthcare directives. |
| Eligibility | Any adult can complete a DNR Order, but it must be signed by a physician and the patient or their authorized representative to be valid. |
| Implementation | The DNR Order must be presented in a visible manner in medical settings, ensuring that healthcare providers are aware of the patient’s wishes during emergencies. |
How to Write California Do Not Resuscitate Order
Completing the California Do Not Resuscitate Order form is an important step for individuals who wish to express their preferences regarding medical treatment in emergency situations. After filling out this form, it is crucial to ensure that it is properly signed, witnessed, and distributed to relevant parties, such as healthcare providers and family members.
- Obtain a copy of the California Do Not Resuscitate Order form. This can typically be found online or through healthcare providers.
- Begin by filling in your full name at the top of the form. Ensure that the name matches the identification documents.
- Provide your date of birth. This information helps to confirm your identity.
- Indicate the date on which you are completing the form. This is essential for record-keeping purposes.
- Next, you will need to select the appropriate box that reflects your wishes regarding resuscitation. Carefully read the options available.
- Sign the form in the designated area. Your signature confirms your intention and understanding of the document.
- Have the form witnessed by at least one person. The witness must also sign and provide their information as required.
- Make copies of the completed form. Distributing these copies to your healthcare providers and family members ensures that your wishes are known.
- Store the original form in a safe place, easily accessible to those who may need it.
California Do Not Resuscitate Order Example
California Do Not Resuscitate (DNR) Order
This Do Not Resuscitate (DNR) Order is executed in accordance with the California Health and Safety Code Section 7190 et seq. It is a legal document that indicates your wish not to undergo cardiopulmonary resuscitation (CPR) in the event of a medical emergency when you are unable to express your wishes.
Patient Information:
- Patient Name: _______________________________
- Date of Birth: _______________________________
- Address: __________________________________
Patient's Physician:
- Physician's Name: _________________________
- Physician's Phone Number: _________________
Patient's Preferences:
The patient hereby explicitly states the following:
- This order applies to situations where the patient experiences a cardiac or respiratory arrest.
- In such an event, no attempts should be made to revive the patient through CPR or other resuscitation efforts.
- The patient wishes to receive comfort care only, including pain relief and emotional support.
Signature: ___________________________________
Date: _______________________________________
Witness Information:
- Witness Name: _____________________________
- Witness Signature: _________________________
- Date: _____________________________________
Please ensure this order is placed in a prominent location and included in your medical record. It is vital to communicate your wishes with family members and healthcare providers.
Other Do Not Resuscitate Order State Forms
Illinois Do Not Resuscitate - An effective DNR order will clearly state the patient's preferences and provide necessary identifiers such as signatures.
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What Does Dnr Mean - A DNR order may reflect cultural or philosophical values regarding end-of-life choices.