Nebraska Do Not Resuscitate (DNR) Order Form
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PH
PHYSICIAN’S DO NOT RESUSCITATE (DNR) ORDER FOR THE MEDICALLY ILL
I, _____________________________________ , have been diagnosed as having a medical illness. I have discussed both the
prognosis of this illness and the treatment options with my physician and request that in the event of my
cardiopulmonary arrest, cardiopulmonary resuscitation and/or mechanical ventilations not be initiated.
I give permission for this information to be given to Emergency Medical Service and Mobile Health Care personnel,
physicians, nurses, or other health care personnel as necessary to carry out these wishes. I understand that this order
is valid from this point forward until rescinded by either myself or my designated Durable Power of Attorney for Health
Care, and further agree that a copy of this form is as valid as the original. Incomplete forms may be returned as being
invalid.

□ DO NOT INTUBATE

I understand that DO NOT INTUBATE means that in the event that my breathing is inadequate
I do not wis