Pennsylvania Do Not Resuscitate Order
This Do Not Resuscitate (DNR) Order is established in accordance with Pennsylvania law. It expresses the wishes of the individual regarding medical treatment in the event of a cardiac or respiratory arrest.
Patient Information:
- Name: ______________________________
- Date of Birth: _______________________
- Address: ____________________________
- City: ________________ State: _____ Zip: ___________
- Patient’s Diagnosis: _________________
Physician Information:
- Physician’s Name: ____________________
- License Number: ______________________
- Contact Number: ______________________
- Address: ____________________________
This order is established based on the voluntary choice of the patient, knowing the consequences of their decision. This DNR order should guide healthcare personnel in emergency situations.
Patient’s Wishes:
- The patient does not wish to receive cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest.
- Other specific wishes regarding treatment: ____________________________
Signature of Patient or Authorized Representative: _______________________ Date: _______________
Signature of Physician: _______________________ Date: _______________
This DNR order is valid until revoked by the patient or their healthcare representative. All healthcare providers must honor this order as per Pennsylvania law.
If changes to the order are needed, please initiate a new document, properly dated and signed.