Healthcare & Wellness
Do Not Resuscitate (DNR) Order
Out-of-hospital DNR order directing emergency personnel and healthcare providers not to attempt cardiopulmonary resuscitation. Requires both patient and physician signatures.
📄 2 signers📅 30-day expiry🏷 Healthcare & Wellness🔖 dnr, end-of-life, healthcare, directive
About this template
The Do Not Resuscitate (DNR) Order is a ready-to-use healthcare & wellness template you can send for signature in minutes. It is written for 2 signers (patient and physician) and, by default, expires 30 days after it is sent if left unsigned. It covers dnr, end of life, healthcare, directive. Like every Abundera Sign template it is a convenience draft structured for ESIGN Act and UETA compliance, not a substitute for legal advice. Each signed copy is sealed with PAdES-LTA digital signatures, dual RFC 3161 timestamps, and a tamper-evident evidence package in WORM storage.
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# Do Not Resuscitate (DNR) Order **Date:** ___________ **Patient Name:** ___________ **Date of Birth:** ___________ **Medical Record Number (if applicable):** ___________ **Primary Care / Attending Physician:** ___________ **Physician License Number:** ___________ **Physician Practice / Hospital:** ___________ ## 1. Directive I, ___________, born on ___________, being of sound mind, hereby direct that in the event my heart stops beating or I stop breathing, no person shall attempt cardiopulmonary resuscitation (CPR), cardiac defibrillation, endotracheal intubation, artificial ventilation, or any other resuscitative measures on my behalf. This order applies in all out-of-hospital settings, including my residence, assisted-living facilities, nursing facilities, and during transport by emergency medical services, except as limited in Section 4 below. ## 2. Scope of This Order (a) **Comfort measures authorized.** Nothing in this order prevents healthcare providers from administering medication for pain, oxygen for comfort, or other palliative care measures intended to reduce discomfort. I specifically authorize: ___________ (b) **Resuscitation measures refused.** The following measures shall not be initiated or continued under any circumstances: chest compressions, rescue breathing, bag-valve-mask ventilation, cardiac defibrillation or cardioversion, administration of resuscitative drugs (e.g., epinephrine, atropine, vasopressors for cardiac arrest), and emergent endotracheal intubation. (c) **Hospitalization.** This order does not prevent hospitalization or transfer to a hospital for treatment of acute conditions other than cardiac arrest. Once hospitalized, the treating facility's policies and my advance directive on file govern. ## 3. Basis for This Decision **Primary Diagnosis / Underlying Condition:** ___________ **Prognosis:** ___________ I have been fully informed of my diagnosis, prognosis, and the likely outcomes of CPR in my particular medical circumstances. I understand that CPR has a low likelihood of restoring meaningful quality of life given my condition and that the procedure may cause pain, injury, and distress without benefit. I make this decision freely and voluntarily. ## 4. Geographic and Facility Scope