Connecticut Do Not Resuscitate (DNR) Order FormConnecticut Do Not Resuscitate (DNR) Order Form
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*571504*
571504

80 Seymour St. P.O. Box 5037
Hartford, CT 06102-5037

DNR INPATIENT ORDER
SECTION ONE DNR ORDER

DNR ORDER – In the event of cardiac arrest, a DNR order indicates no cardiopulmonary resuscitation (CPR)
including no basic life support (no cardiac compressions, no artificial ventilation) and no advanced cardiac life support (no
defibrillation, no endotracheal intubation, no administration of Advanced Cardiac Life Support (ACLS) medications
including no vasopressors).
Therefore, a DNR order means no cardiac or respiratory resuscitative efforts will be initiated as described above. All
measures to ensure the patient’s comfort and respect for dignity will be maintained.
A "Do Not Resuscitate" (DNR) order must be accompanied by a note in the space below documenting the discussion with the patient or
any authorized representative of an incapacitated patient. Include the reason for the patient’s incapacity, diagnosis, prognosis, names
of participants involved in discussion and