Do Not Resuscitate Order Document for Oregon State

Oregon Do Not Resuscitate Order (DNR)

This document is prepared in accordance with the Oregon Revised Statutes and serves as a directive for health care providers, indicating that the individual named below does not wish to have cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest. Please complete the information accurately to ensure that your medical care preferences are honored.

Patient Information:

• Patient Name: __________________________
• Date of Birth: __________________________
• Address: __________________________
• City, State, Zip: __________________________
• Phone Number: __________________________

Do Not Resuscitate Directive:

I, __________________________ (Patient Name), understand the nature and effect of a Do Not Resuscitate Order. I direct that no form of cardiopulmonary resuscitation (CPR) be initiated in the event of my cardiac or respiratory arrest. This decision is made after careful consideration, and it reflects my desires concerning my medical treatment.

Physician Information:

• Physician Name: __________________________
• License Number: __________________________
• Address: __________________________
• City, State, Zip: __________________________
• Phone Number: __________________________

Physician Declaration:

I, __________________________ (Physician Name), certify that I have discussed the nature, importance, and implications of a Do Not Resuscitate Order with the patient named above, who has been determined to be of sound mind and has voluntarily elected to implement this order.

Signatures:

Patient Signature: __________________________

Date: __________________________

If the patient is unable to sign:

Signature of Legal Guardian, Healthcare Representative, or Next of Kin: __________________________

Name: __________________________ Relationship to Patient: __________________________

Date: __________________________

Physician Signature: __________________________

Date: __________________________

Instructions for Implementation:

This Do Not Resuscitate Order must be reviewed periodically and maintained in an easily accessible location. If the patient elects to rescind this order, it is their responsibility to notify their healthcare provider immediately.