Kentucky Do Not Resuscitate (DNR) Order FormKentucky Do Not Resuscitate (DNR) Order Form
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Kentucky Emergency Medical Services
Do Not Resuscitate (DNR) Order
Person's Full Legal Name _______________________________________________________________
Surrogate's Full Legal Name (if applicable) _________________________________________________
I, the undersigned person or surrogate who has been designated to make health care decisions in
accordance with Kentucky Revised Statutes, hereby direct that in the event of my cardiac or respiratory
arrest that this DO NOT RESUSCITATE (DNR) ORDER be honored. I understand that DNR means that if
my heart stops beating or if I stop breathing, no medical procedure to restart breathing or heart function,
more specifically the insertion of a tube into the lungs, or electrical shocking of the heart or cardiopulmonary
resuscitation (CPR) will be started by emergency medical services (EMS) personnel.
I understand this decision will not prevent emergency medical services personnel from providing other
medical care.
I understand that I may revoke thi