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California Do Not Resuscitate Order

This form is a Do Not Resuscitate (DNR) order in accordance with California state law. It is a legal document expressing a person's wishes regarding resuscitation in case of a medical emergency.

Patient Information:

  • Patient's Full Name: ____________________________
  • Date of Birth: ____________________________
  • Address: ____________________________
  • City: ____________________________
  • State: ____________________________
  • ZIP Code: ____________________________

Physician Information:

  • Physician's Name: ____________________________
  • Contact Number: ____________________________
  • Medical License Number: ____________________________

Statement of Wishes:

I, (Patient's Name), hereby request that in the event my heart stops beating or I stop breathing, no attempts be made to resuscitate me. This order applies when I am unable to communicate my wishes and is intended to be followed by medical personnel.

Signature:

  • Patient's Signature: ____________________________
  • Date: ____________________________

Witness Information:

  • Witness Name: ____________________________
  • Witness Signature: ____________________________
  • Date: ____________________________

Important Notes:

  1. This form should be kept in a safe but accessible location.
  2. A copy of this order should be shared with your healthcare provider and family members.
  3. This DNR order should comply with all applicable state laws and regulations.

Form Data

Fact Name Details
Definition A California Do Not Resuscitate (DNR) Order is a legal document that informs medical personnel not to perform CPR if a patient's heart stops or they stop breathing.
Governing Law The DNR Order is governed by California Health and Safety Code Section 7180-7190.
Eligibility Any adult who is capable of making their own healthcare decisions can complete a DNR Order.
Signature Requirement The form must be signed by the patient, or by their legally authorized representative, to be valid.
Healthcare Provider Role Healthcare providers are required to honor a valid DNR Order and cannot perform resuscitation if it is in place.

California Do Not Resuscitate Order - Usage Guidelines

Completing the California Do Not Resuscitate Order form is an important step in ensuring your healthcare preferences are respected. After filling out the form, it should be signed and given to your healthcare provider. They will keep it on file and ensure that your wishes are honored in a medical emergency.

  1. Obtain the California Do Not Resuscitate Order form. You can find it online or request a copy from your healthcare provider.
  2. Fill in your full name, date of birth, and address at the top of the form.
  3. Indicate whether you are completing this form for yourself or if you are a legal representative acting on behalf of someone else.
  4. Provide the name of the person who will be the legal representative, if applicable.
  5. Clearly state your wishes regarding resuscitation by checking the appropriate box on the form.
  6. Sign and date the form. If you are completing it on behalf of someone else, ensure that you also include your signature as the representative.
  7. Have the form witnessed by two individuals who are not related to you and who do not stand to benefit from your estate.
  8. Make copies of the signed form for your records and for your healthcare provider.

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Dos and Don'ts

When filling out the California Do Not Resuscitate (DNR) Order form, it is essential to follow specific guidelines to ensure that your wishes are accurately represented. Here are some important dos and don'ts to keep in mind:

  • Do consult with your healthcare provider to understand the implications of a DNR order.
  • Do ensure that the form is signed by you and your physician.
  • Do keep copies of the completed DNR order in accessible locations, such as with your medical records.
  • Do discuss your decision with family members to avoid confusion in an emergency.
  • Don't fill out the form without fully understanding its consequences.
  • Don't forget to date the form when signing it.
  • Don't assume that verbal instructions will be honored; always use the official form.
  • Don't neglect to review and update your DNR order as your health situation changes.

Common mistakes

  1. Not Understanding the Purpose: Many individuals fill out the Do Not Resuscitate (DNR) Order form without fully grasping its implications. A DNR order is a legal document that indicates a person does not wish to receive cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest. It’s crucial to understand that this decision is significant and should align with personal health care goals.

  2. Inaccurate Information: Providing incorrect personal information is a common mistake. It’s essential to ensure that your name, date of birth, and other identifying details are accurate. Errors can lead to confusion and may result in the DNR not being honored when needed.

  3. Not Signing the Form: Some individuals neglect to sign the DNR form. A signature is necessary to validate the document. Without it, medical personnel may not recognize the order, potentially leading to unwanted resuscitation efforts.

  4. Failure to Communicate: After completing the DNR form, failing to discuss it with family members and healthcare providers is a frequent oversight. Open communication ensures that everyone involved understands your wishes and can act accordingly in an emergency situation.

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