Pennsylvania Do Not Resuscitate (DNR) Order Form – Sample OnlyPennsylvania Do Not Resuscitate (DNR) Order Form – Sample Only
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OUT-OF-HOSPITAL DO-NOT-RESUSCITATE ORDER
1.

Patient’s Name:______________________________________________________

2A. Attending Physician Statement:
I, the undersigned, state that I am the attending physician of the patient named above. The above-named patient, or the
patient’s surrogate or other person by virtue of that person’s legal relationship to the patient, has requested this order, and I
have made a determination that this patient is eligible for an order and satisfies one of the following: (1) the patient has an
end-stage medical condition; (2) the patient is in a terminal condition; (3) the patient is permanently unconscious and has a
living will directing that no cardiopulmonary resuscitation be provided to the patient in the event of the patient’s cardiac or
respiratory arrest; or (4) the patient is permanently unconscious and has a living will authorizing the surrogate or other person
named below to request an out-of-hospital do-not-resuscitate order for the patient. I d