An out of hospital DNR declaration and
order must be in substantially the following form:
OUT OF HOSPITAL DO NOT RESUSCITATE DECLARATION
AND ORDER
This declaration and order is effective on the date of execution and
remains in effect until the death of the declarant or revocation.
OUT OF HOSPITAL DO NOT RESUSCITATE DECLARATION
Declaration made this ____ day of __________. I, _____________,
being of sound mind and at least eighteen (18) years of age, willfully
and voluntarily make known my desires that my dying shall not be
artificially prolonged under the circumstances set forth below. I
declare:
My attending physician, advanced practice registered nurse, or
physician assistant has certified that I am a qualified person, meaning
that I have a terminal condition or a medical condition such
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An out of hospital DNR declaration and
order must be in substantially the following form:
OUT OF HOSPITAL DO NOT RESUSCITATE DECLARATION
AND ORDER
This declaration and order is effective on the date of execution and
remains in effect until the death of the declarant or revocation.
OUT OF HOSPITAL DO NOT RESUSCITATE DECLARATION
Declaration made this ____ day of __________. I, _____________,
being of sound mind and at least eighteen (18) years of age, willfully
and voluntarily make known my desires that my dying shall not be
artificially prolonged under the circumstances set forth below. I
declare:
My attending physician, advanced practice registered nurse, or
physician assistant has certified that I am a qualified person, meaning
that I have a terminal condition or a medical condition such that, if I
suffer cardiac or pulmonary failure, resuscitation would be
unsuccessful or within a short period I would experience repeated
cardiac or pulmonary failure resulting in death.
I direct that, if I experience cardiac or pulmonary failure in a
location other than an acute care hospital or a health facility,
cardiopulmonary resuscitation procedures be withheld or withdrawn
and that I be permitted to die naturally. My medical care may include
any medical procedure necessary to provide me with comfort care or
to alleviate pain.
I understand that I may revoke this out of hospital DNR declaration
at any time by a signed and dated writing, by destroying or canceling
this document, or by communicating to health care providers at the
scene the desire to revoke this declaration.
This declaration was signed by me and by the witnesses in
compliance with Indiana law and by: [Initial or check only one (1) of
the following spaces]
__ Signing on paper or electronically in each other's direct physical
presence.
__ Signing in separate counterparts on paper using two (2) way, real
time audiovisual technology.
__ Signing electronically using two (2) way, real time audiovisual
technology or telephonic interaction.
__ Signing in separate counterparts on paper using telephonic
interaction between me (the declarant) and all witnesses.
I understand the full import of this declaration.
IF THE DECLARANT IS INCAPACITATED OR INCOMPETENT,
the adult who signed above for the declarant is the: [Initial or check
only one (1) of the following spaces]
__ Court appointed guardian of the declarant's person.
__ Agent or attorney in fact (POA) under the declarant's heath care
power of attorney.
__ Health care representative for the declarant under a written advance
directive or other written appointment.
__ Proxy for the declarant (state relationship to declarant)
_________________________
Address and other optional contact information for guardian, agent,
representative, or proxy who signed for the declarant:
_______________________________________________________
________________________________________________________
The declarant is personally known to me, and I believe the declarant
to be of sound mind. I did not sign the declarant's signature above, for,
or at the direction of, the declarant. I am not a parent, spouse, or child
of the declarant. I am not entitled to any part of the declarant's estate or
directly financially responsible for the declarant's medical care. I am
competent and at least eighteen (18) years of age.
Witness____________Printed name___________Date__________
Witness____________Printed name___________Date__________
OUT OF HOSPITAL DO NOT RESUSCITATE ORDER
I,___________________, the attending physician, advanced
practice registered nurse, or physician assistant of
_________________, have certified the declarant as a qualified person
to make an out of hospital DNR declaration, and I order health care
providers having actual notice of this out of hospital DNR declaration
and order not to initiate or continue cardiopulmonary resuscitation
procedures on behalf of the declarant, unless the out of hospital DNR
declaration is revoked.