Printable  Do Not Resuscitate Order Template for Pennsylvania Customize Document Here

Printable Do Not Resuscitate Order Template for Pennsylvania

A Pennsylvania Do Not Resuscitate (DNR) Order form is a legal document that allows individuals to express their wishes regarding resuscitation efforts in the event of a medical emergency. This form is crucial for ensuring that a person's preferences about life-sustaining treatment are respected by healthcare providers. Understanding how to properly complete and utilize this form can help individuals and their families navigate difficult healthcare decisions.

Customize Document Here
Outline

The Pennsylvania Do Not Resuscitate (DNR) Order form serves as a crucial legal document that empowers individuals to express their wishes regarding medical treatment in the event of a life-threatening situation. This form is particularly significant for patients with serious health conditions who may wish to decline resuscitation efforts, such as cardiopulmonary resuscitation (CPR), in the event of cardiac arrest or respiratory failure. The DNR form must be completed and signed by a physician, ensuring that medical professionals are aware of the patient's preferences. Additionally, the form includes essential information such as the patient's name, date of birth, and the signature of a witness, which helps validate the document. It is important for individuals to discuss their wishes with family members and healthcare providers to ensure that everyone is aligned. Once completed, the DNR Order should be kept in an accessible location, allowing emergency personnel to act in accordance with the patient’s wishes during critical moments. Understanding the intricacies of the Pennsylvania DNR Order form can help individuals navigate the complexities of end-of-life care while ensuring their preferences are honored.

Preview - Pennsylvania Do Not Resuscitate Order Form

Pennsylvania Do Not Resuscitate (DNR) Order Template

This document serves as a Do Not Resuscitate (DNR) Order under the specific provisions of Pennsylvania law, notably the Pennsylvania Out-of-Hospital Do-Not-Resuscitate Act. A DNR order instructs medical personnel not to perform cardiopulmonary resuscitation (CPR) on the person named in the order in case their breathing stops or if their heart stops beating.

Please fill out the following information to complete your Pennsylvania DNR Order:















Statement of Understanding:

I, __________(Patient's Full Name)__________, understand that this document directs all Emergency Medical Services (EMS) personnel and healthcare providers acting under the laws of the Commonwealth of Pennsylvania not to attempt resuscitation in the event of my cardiac or respiratory arrest.

I am aware of the nature and purpose of this document, completely understand its effect, and choose to execute it voluntarily, without any coercion or undue influence.

Patient or Legal Guardian's Signature:

  • Patient's Signature (or Legal Guardian if applicable): _________________________
  • Date: _________________________

Physician's Declaration:

I, __________(Physician's Full Name)__________, certify that I am the physician of the patient named above and that this DNR order is appropriate for the patient based on their current health condition.

  • Physician's Signature: _________________________
  • Date: _________________________
  • License Number: _________________________

Witness Declaration (Optional):

This section can be filled to provide additional verification of the DNR order. Witnessing is not mandatory under Pennsylvania law but can serve as an additional layer of validation.

  • Witness Name: _________________________
  • Witness Signature: _________________________
  • Date: _________________________

This document is made under the laws of the Commonwealth of Pennsylvania and should be honored across all healthcare settings within the state.

Document Data

Fact Name Details
Purpose The Pennsylvania Do Not Resuscitate (DNR) Order form allows individuals to refuse resuscitation efforts in case of cardiac or respiratory arrest.
Governing Law The DNR Order is governed by the Pennsylvania Consolidated Statutes, Title 20, Chapter 54.
Eligibility Any adult who is capable of making medical decisions can complete a DNR Order.
Signature Requirement The form must be signed by the individual or their authorized representative.
Healthcare Provider's Role A physician must sign the DNR Order for it to be valid. This confirms that the decision is based on medical advice.
Form Availability The DNR Order form is available through healthcare providers and various online resources.
Revocation Individuals can revoke a DNR Order at any time, and this can be done verbally or in writing.
Emergency Services Emergency medical services (EMS) must honor a valid DNR Order when presented at the scene.
Please rate Printable Do Not Resuscitate Order Template for Pennsylvania Form
4.75
(Stellar)
16 Votes