Maine Do Not Resuscitate (DNR) Order Form
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This section is optional. If you do not want ambulance crews to revive you if your heart or breathing
stops, you and your physician (or nurse practitioner or physician assistant) must complete and sign this
FOR PATIENT TO COMPLETE after consultation with his or her health care provider:
In the event that my heart or breathing stops and I am unable to speak for myself, I, ___________________
(printed name)direct that no efforts be taken to restart my heart or breathing and that Emergency
Medical Services (ambulance crews) if notified, honor my directive. I have come to this decision after
considering my condition and prognosis and the potential risks, burdens and benefits of refusing efforts to
restart my heart or breathing.
I understand that I may change my mind at any time by destroying this form and removing any Maine
EMS approved Do-Not-Resuscitate jewelry, such as MedicAlert. I will also tell my physician (or nurse
practitioner or physician