• DO-NOT-RESUSCITATE • DNR • DO-NOT-RESUSCITATE • DNR • DO-NOT-RESUSCITATE • DNR • DO-NOT-RESUSCITATE • DNR • (Page 1 of 2) Illinois Department of Public Health UNIFORM DO-NOT-RESUSCITATE (DNR) ADVANCE DIRECTIVE Patient Directive I, _____________________________, born on ____________, hereby direct the following in the event of: (print full name) (birth date) 1. FULL CARDIOPULMONARY ARREST (When both breathing and heartbeat stop): x K Do Not Attempt Cardiopulmonary Resuscitation (CPR) (Measures to promote patient comfort and dignity will be provided.) 2. PRE-ARREST EMERGENCY (When breathing is labored or stopped, and heart is still beating): SELECT ONE K Do Attempt Cardiopulmonary Resuscitation (CPR) -ORK Do Not Attempt Cardiopulmonary Resuscitation (CPR) (Measures to promote patient comfort and dignity will be provided.) Other Instructions __________________________________________________________________ __________________________________________________________________________________ Patient Directive Authorization and Consent to DNR Order (Required to be a valid DNR Order) I understand and authorize the above Patient Directive, and consent to a physician DNR Order implementing this Patient Directive. ________________________________________ Printed name of individual ________________________________________ Signature of individual ________________ Date ________________________________________ Printed name of (circle appropriate title): legal guardian OR agent under health care power of attorney OR healthcare surrogate decision maker ________________________________________ Signature of legal representative ________________ Date -OR- Witness to Consent (Required to have two witnesses to be a valid DNR Order) I am 18 years of age or older and have witnessed the giving of consent by the above person. ________________________________________ Printed name of witness ________________________________________ Signature of witness ________________ Date ________________________________________ Printed name of witness ________________________________________ Signature of witness ________________ Date Physician Signature (Required to be a valid DNR Order) I hereby execute this DNR Order on ________________________________________ Signature of attending physician _____________________. Today’s date ________________________________________ Printed Name of attending physician ___________________________ Physician’s telephone number N Send this form or a copy of both sides with the individual upon transfer or discharge. N DNR • DO-NOT-RESUSCITATE • DNR • DO-NOT-RESUSCITATE • DNR • DO-NOT-RESUSCITATE • DO-NOT-RESUSCITATE • DNR • DO-NOT-RESUSCITATE • DNR • DO-NOT-RESUSCITATE • DNR • DO-NOT-RESUSCITATE • DNR • DO-NOT-RESUSCITATE • DNR • DO-NOT-RESUSCITATE • DNR • DO-NOT-RESUSCITATE • DNR American LegalNet, Inc. www.USCourtForms.com • DO-NOT-RESUSCITATE • DNR • DO-NOT-RESUSCITATE • DNR • DO-NOT-RESUSCITATE • DNR • DO-NOT-RESUSCITATE • DNR • (Page 2 of 2) Illinois Department of Public Health UNIFORM DO-NOT-RESUSCITATE (DNR) ADVANCE DIRECTIVE Patient’s name ____________________________________________________ Summarize medical condition: When This Form Should Be Reviewed This DNR order, in effect until revoked, should be reviewed periodically, particularly if – • • • The patient/resident is transferred from one care setting or care level to another, or There is a substantial change in patient/resident health status, or The patient/resident treatment preferences change. 1. 2. Review the other side of this form. Complete the following section. If this form is to be voided, write “VOID” in large letters on the other side of the form. After voiding the form, a new form may be completed. How to Complete the Form Review Date Reviewer Location of review Outcome of Review Date Reviewer Location of review Outcome of Review Date Reviewer Location of review K K K No change FORM VOIDED; new form completed FORM VOIDED; no new form completed K K K No change FORM VOIDED; new form completed FORM VOIDED; no new form completed Outcome of Review K K K Advance Directives I also have the following advance directives: K Health Care Power of Attorney K Living Will K Mental Health Treatment Preference Declaration No change FORM VOIDED; new form completed FORM VOIDED; no new form completed Contact person (name and phone number) ______________________________________________ ______________________________________________ ______________________________________________ N Send this form or a copy of both sides with the individual upon transfer or discharge. N Printed by Authority of the State of Illinois • P.O.335136 100M 5/05 DNR • DO-NOT-RESUSCITATE • DNR • DO-NOT-RESUSCITATE • DNR • DO-NOT-RESUSCITATE • DO-NOT-RESUSCITATE • DNR • DO-NOT-RESUSCITATE • DNR • DO-NOT-RESUSCITATE • DNR • DO-NOT-RESUSCITATE • DNR • DO-NOT-RESUSCITATE • DNR • DO-NOT-RESUSCITATE • DNR • DO-NOT-RESUSCITATE • DNR American LegalNet, Inc. www.USCourtForms.com