DO NOT RESUSCITATE
ALL FIRST RESPONDERS AND EMERGENCY MEDICAL
SERVICES PERSONNEL ARE AUTHORIZED TO COMPLY
WITH THIS OUT-OF-HOSPITAL DNR ORDER.
This request for no resuscitative attempts in the event of a cardiac and/or respiratory arrest for:
______________________________________,has been ordered by the physician whose signature
PLEASE PRINT NAME
appears below. This order is in compliance with the patient’s/surrogate’s wishes and it has been
determined and documented by the physician below that resuscitation attempts for this patient would be
It is expected that this DNR order shall be honored by all Emergency Medical Services (EMS)
personnel, First Responders, and other healthcare providers who may have contact with this patient
during a medical emergency.
PATIENT ADDRESS: ________________________________________________________________
THE ABOVE NAMED PATIENT IS U