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Uniform Do-Not-Resuscitate (DNR) Advance Directive Form. This is a Illinois form and can be use in Miscellaneous Statewide.
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Tags: Uniform Do-Not-Resuscitate (DNR) Advance Directive, Illinois Statewide, Miscellaneous
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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 a witness to be a valid DNR Order)
I am 18 years of age or older and acknowledge the above person has had an opportunity to read this form
and have witnessed the giving of consent by the above person or the above person has acknowledged his/her
signature or mark on this form in my presence.
________________________________________
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
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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
K
K
K
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
Outcome of Review
Advance Directives
I also have the following advance directives:
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
Contact person (name and phone number)
______________________________________________
______________________________________________
______________________________________________
N Send this form or a copy of both sides with the individual upon transfer or discharge. N
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