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Pennsylvania Do Not Resuscitate Order
This Do Not Resuscitate (DNR) Order is made in accordance with the Pennsylvania Medical Assistance Law and the Pennsylvania Do Not Resuscitate Act.
Patient Information:
- Name: ______________________________________
- Date of Birth: ____________________________
- Address: ____________________________________
- Phone Number: ____________________________
Physician Information:
- Physician Name: ____________________________
- Medical License Number: ___________________
- Phone Number: ____________________________
Patient Designation:
- Revocation: The patient can revoke this order at any time.
- Effective Date: This order is effective as of ________________.
- Witness Signature: ___________________________
By signing below, I confirm that I have discussed this DNR order with the patient and that it reflects their wishes.
Patient Signature (or Legal Guardian): _______________________
Date: ________________
Witness Signature: _______________________
Date: ________________
It is important to keep this document in a noticeable place and inform family members and other healthcare providers of its existence.
Form Data
| Fact Name | Description |
|---|---|
| Purpose | The Pennsylvania Do Not Resuscitate (DNR) Order form allows individuals to express their wish not to receive cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest. |
| Governing Law | The DNR Order in Pennsylvania is governed by the Pennsylvania Consolidated Statutes, Title 20, Chapter 54, known as the "Health Care Decisions Law." |
| Eligibility | Any adult who is capable of making health care decisions can complete a DNR Order. This includes individuals with terminal illnesses or those who wish to avoid aggressive life-saving measures. |
| Signature Requirement | The form must be signed by the patient or their authorized representative, and it must be witnessed by two adults who are not related to the patient or beneficiaries of their estate. |
Pennsylvania Do Not Resuscitate Order - Usage Guidelines
Completing the Pennsylvania Do Not Resuscitate Order form is an important step for individuals wishing to communicate their healthcare preferences. This process involves careful consideration and clear communication with healthcare providers and loved ones. Below are the steps to fill out the form accurately.
- Obtain the Pennsylvania Do Not Resuscitate Order form. This can typically be found online or requested from a healthcare provider.
- Read the instructions on the form thoroughly to ensure you understand each section.
- Fill in your personal information, including your full name, date of birth, and address.
- Indicate your decision regarding resuscitation by checking the appropriate box. Make sure this reflects your wishes clearly.
- Provide the name and contact information of your healthcare provider. This step is crucial for ensuring that your wishes are known and respected.
- Sign and date the form. Your signature confirms that you understand the implications of your decision.
- Have the form witnessed by two adults who are not related to you and do not stand to benefit from your estate. Their signatures will validate your order.
- Make copies of the completed form. Keep one for your records and provide copies to your healthcare provider and any family members involved in your care.
Once the form is completed and distributed, it is essential to discuss your wishes with your healthcare provider and family members. This ensures everyone is aware of your preferences and can act accordingly in a medical situation.
Some Other Do Not Resuscitate Order State Templates
How Old Do You Have to Be to Sign a Dnr - This order can also be known as a Do Not Attempt Resuscitation (DNAR) order.
A Colorado Do Not Resuscitate (DNR) Order form is a legal document that allows individuals to refuse resuscitation efforts in the event of a medical emergency. This form ensures that a person's wishes regarding life-sustaining treatment are respected by healthcare providers. Understanding how to properly complete and utilize this form is essential for anyone considering their end-of-life care options, and resources such as Colorado PDF Templates can provide valuable assistance.
What Does Dnr Mean - A DNR can be a comfort to families, knowing that their loved one’s wishes will be respected in critical situations.
Dnr Rules and Regulations - A vital part of respecting a patient’s self-determination in health care decisions.
Dos and Don'ts
When filling out the Pennsylvania Do Not Resuscitate Order form, it's important to follow specific guidelines to ensure that your wishes are clearly communicated. Here’s a list of things to do and avoid:
- Do consult with your healthcare provider before completing the form.
- Do ensure that the form is signed by both you and your physician.
- Do keep a copy of the completed form in an easily accessible location.
- Do inform your family members and loved ones about your decision.
- Don't leave any sections of the form blank.
- Don't sign the form without understanding its implications.
- Don't forget to date the form when you sign it.
- Don't assume that verbal instructions are sufficient; always use the official form.
Common mistakes
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Not Including Proper Identification: Individuals often forget to include essential identifying information, such as their full name, date of birth, and address. This information is crucial for ensuring that the order is valid and can be properly executed by medical personnel.
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Failure to Sign the Form: Some people neglect to sign the Do Not Resuscitate Order form. A signature is necessary for the document to be legally binding. Without it, healthcare providers may not honor the request.
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Inadequate Witnessing: The form typically requires witnesses to validate the order. Individuals may not follow the guidelines for who can serve as a witness, leading to potential disputes about the form's legitimacy. Witnesses must be of a certain age and cannot be related to the patient.
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Not Reviewing the Document Regularly: A Do Not Resuscitate Order should be reviewed periodically. People often forget to update their preferences as their health status changes or as they experience new medical conditions. An outdated order may not reflect their current wishes.