Article Guide
The New York Do Not Resuscitate (DNR) Order form serves as a crucial document for individuals who wish to express their preferences regarding emergency medical interventions, particularly in situations where resuscitation may be required. This form allows patients to communicate their wishes clearly to healthcare providers, ensuring that their choices are respected in critical moments. The DNR Order is specifically designed for use in out-of-hospital settings, such as at home or in long-term care facilities, and it must be completed by a physician in conjunction with the patient or their designated representative. Key elements of the form include the patient's identification details, the physician's information, and a clear declaration of the patient's desire not to receive cardiopulmonary resuscitation (CPR) or other life-sustaining measures. Additionally, the form provides space for signatures, which are essential for validating the order and making it legally binding. Understanding the implications of this document is vital for both patients and their families, as it reflects personal values and medical preferences during end-of-life care. By utilizing the DNR Order form, individuals can take proactive steps in managing their healthcare decisions, ensuring that their rights and wishes are honored in times of medical crisis.
Preview - New York Do Not Resuscitate Order Form
New York Do Not Resuscitate Order (DNR)
This document is designed to comply with the New York State Public Health Law Article 29-B, the Family Health Care Decisions Act, and related regulations. It represents a legal order, written by a New York State licensed physician, nurse practitioner, or physician assistant (where allowed under state law), indicating that cardiopulmonary resuscitation (CPR) should not be attempted if a person's breathing stops or if the person's heart stops beating.
Personal Information
Name of Patient: _______________________________________________________
Date of Birth: ____________________ (MM/DD/YYYY)
Address: ________________________________________________________________
Telephone Number: _______________________________________________________
New York State Identification or Driver License Number: ______________________
Medical Information
Primary Physician/Nurse Practitioner/Physician Assistant Name: ______________________________________
License Number: _________________________________________________________
Contact Number: _________________________________________________________
Medical Facility: ________________________________________________________
This Do Not Resuscitate Order is based on (check appropriate reason):
- The patient's prior express wish, including relevant written documents, such as living wills or health care proxies.
- A decision by the health care agent, made in accordance with the New York Health Care Proxy Law, reflecting the patient's wishes or the patient's best interests if the patient's wishes are not known.
- A decision by a surrogate, made in accordance with the New York Family Health Care Decisions Act, reflecting the patient's best interests.
Signature
I, the undersigned, affirm that this Do Not Resuscitate Order reflects the patient's wishes or best interests and is in compliance with New York State laws and regulations.
_________________________________________________
Signature of Physician/Nurse Practitioner/Physician Assistant
Date: ____________________ (MM/DD/YYYY)
Patient (or Legal Healthcare Proxy/Surrogate) Acknowledgment:
I affirm that I have been fully informed of the nature and purpose of a Do Not Resuscitate Order, the consequences of such an order, and the alternatives to accepting this order. I authorize this order, understanding that I may revoke it at any time.
_________________________________________________
Signature of Patient or Legal Healthcare Proxy/Surrogate
Date: ____________________ (MM/DD/YYYY)
This document should be reviewed periodically and can be revoked by the patient or the patient's legal healthcare proxy/surrogate at any time. A new order must be completed and signed in the event of revocation or if the patient is transferred to another facility or care setting.
PDF Specifications
| Fact Name | Description |
|---|---|
| Definition | A Do Not Resuscitate (DNR) Order is a medical order that instructs healthcare providers not to perform CPR if a patient's heart stops beating or they stop breathing. |
| Governing Law | The New York DNR Order is governed by the New York Public Health Law, specifically Article 29-B. |
| Eligibility | Any adult can create a DNR order, and it is typically used for individuals with terminal illnesses or severe medical conditions. |
| Form Requirements | The DNR order must be signed by a physician and the patient or their legal representative to be valid. |
| Revocation | A DNR order can be revoked at any time by the patient or their legal representative, and this should be documented in writing. |
| Placement | It is recommended that the DNR order be placed in a visible location, such as on the refrigerator or in the patient's medical records. |
| Emergency Medical Services | Emergency Medical Services (EMS) personnel are required to honor a valid DNR order when responding to a medical emergency. |
| Patient Rights | Patients have the right to make decisions about their medical care, including the choice to refuse resuscitation efforts. |
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