A Do Not Resuscitate (DNR) Order form in Arkansas allows individuals to express their wish not to receive cardiopulmonary resuscitation (CPR) in the event of cardiac arrest. This legal document ensures that medical professionals respect the patient's preferences regarding life-saving measures. To take control of your healthcare decisions, consider filling out the form by clicking the button below.
In the realm of healthcare, the Arkansas Do Not Resuscitate (DNR) Order form serves as a crucial document for individuals who wish to express their preferences regarding medical interventions during critical moments. This form empowers patients to communicate their desires about resuscitation efforts in the event of a cardiac arrest or respiratory failure. It is designed to ensure that medical professionals respect the wishes of patients, particularly those facing terminal illnesses or advanced medical conditions. The DNR Order must be completed and signed by a qualified physician, and it is essential for patients to discuss their choices with their families and healthcare providers. In Arkansas, the DNR form is recognized across various healthcare settings, including hospitals, nursing homes, and even in home care situations. Understanding the implications of this document can provide peace of mind, allowing individuals to take control of their end-of-life care decisions in a compassionate and dignified manner.
Arkansas Do Not Resuscitate Order (DNR)
In accordance with the Arkansas Department of Health guidelines, this document serves as a directive for individuals seeking to establish a Do Not Resuscitate (DNR) order. This legal document indicates the patient's wish to decline resuscitation in the event of cardiac or respiratory arrest. Please complete all sections to ensure your wishes are clearly documented and can be lawfully respected by healthcare providers.
Patient Information
Patient Name: ___________________________________
Date of Birth: ___________________________________
Address: ________________________________________
City: ___________________ State: AR Zip: _________
Primary Phone: _________________________________
Alternative Phone: ______________________________
Medical Information
Primary Physician: ______________________________
Physician Phone: ________________________________
Medical Conditions: _____________________________
________________________________________________
Do Not Resuscitate (DNR) Directive
I, __________________________________ (Patient Name), hereby direct all medical personnel to withhold cardiopulmonary resuscitation (CPR) in the event that my breathing or heart stops. This decision is made voluntarily and with full understanding of the consequences. I have discussed my condition and treatment preferences with my healthcare provider, who has provided me with comprehensive information regarding the nature and effect of a DNR order.
This DNR order is to remain in effect until revoked. I understand that I may cancel or alter this order at any time by providing written notification to my healthcare providers.
Signature
Patient Signature: _______________________________ Date: _______________
If the patient is unable to sign, a designated healthcare proxy, guardian, or power of attorney may sign on the patient's behalf:
Print Name: _____________________________________ Relationship: _________________
Signature: ______________________________________ Date: _______________
Physician Certification
I, ____________________________ (Physician Name), certify that I have discussed the nature and effect of a Do Not Resuscitate (DNR) order with the patient or their designated representative. I have provided them with all the necessary information to make an informed decision, and I respect this declaration as reflecting the patient's current medical preferences and directives.
Physician Signature: _____________________________ Date: _______________
Medical License Number: _________________________
Important Information
This Do Not Resuscitate Order is based on current Arkansas state guidelines and laws. It is the patient's responsibility, or their designated representative's, to ensure that this document is accessible to healthcare providers. Patients are encouraged to discuss this document with their family, healthcare proxy, or guardian to ensure their wishes are understood and will be followed. A DNR order does not affect the provision of other forms of medical care, including pain relief, nutrition, and hydration.
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