Official Do Not Resuscitate Order Template for the State of New Jersey Make Your Document Now

Official Do Not Resuscitate Order Template for the State of New Jersey

A Do Not Resuscitate (DNR) Order form is a legal document that allows individuals to refuse certain life-saving medical interventions, specifically cardiopulmonary resuscitation (CPR), in the event of cardiac arrest. In New Jersey, this form serves to communicate a patient's wishes regarding resuscitation efforts to healthcare providers. Understanding the implications of this document is crucial for both patients and their families in making informed healthcare decisions.

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Similar forms

  • Living Will: A living will outlines a person's wishes regarding medical treatment in situations where they cannot communicate. Like a DNR, it provides guidance on what actions should or should not be taken in critical health situations.
  • Healthcare Power of Attorney: This document allows an individual to designate someone to make healthcare decisions on their behalf. It complements a DNR by ensuring that a trusted person can advocate for the patient's wishes.
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  • Advance Healthcare Directive: An advance healthcare directive combines a living will and a healthcare power of attorney. It serves to express treatment preferences and appoint someone to make decisions, much like a DNR.
  • Physician Orders for Life-Sustaining Treatment (POLST): A POLST form translates a patient’s wishes into medical orders. It is similar to a DNR in that it specifically addresses the patient’s preferences for resuscitation and other life-sustaining treatments.
  • Do Not Intubate (DNI) Order: A DNI order specifies that a patient should not be intubated if they stop breathing. This document focuses on a specific aspect of resuscitation, similar to the broader scope of a DNR.
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Document Sample

New Jersey Do Not Resuscitate (DNR) Order

This Do Not Resuscitate Order (DNR) is issued in compliance with New Jersey law regarding advance directives. It expresses the wish of the individual regarding resuscitation efforts in the event of cardiac or respiratory arrest.

Patient Information:

  • Name: ____________________________
  • Date of Birth: ______________________
  • Medical Record Number: _____________
  • Address: ___________________________
  • Contact Information: _________________

Order Statement:

I, the undersigned, hereby declare that if my heart stops beating or if I stop breathing, I do not want any resuscitative measures to be performed.

Signature: __________________________

Date: ______________________________

Health Care Proxy / Surrogate Information:

  • Name: ____________________________
  • Relationship to Patient: _____________
  • Contact Information: _________________

This DNR Order should be provided to the healthcare team and kept in the patient's medical record to ensure compliance with these wishes. It must be signed by the patient or their authorized representative.

Witness Signatures:

  1. Name: ____________________________ Signature: ____________________________
  2. Name: ____________________________ Signature: ____________________________

This document is effective immediately upon signing and remains in effect until revoked by the patient or their authorized representative.

Download Do Not Resuscitate Order PDF

Key takeaways

Understanding the New Jersey Do Not Resuscitate (DNR) Order form is crucial for anyone considering their end-of-life care preferences. Here are some key takeaways to keep in mind:

  • Clear Communication: The DNR order must be clearly communicated to all healthcare providers. This ensures that your wishes are respected in emergency situations.
  • Proper Completion: The form must be filled out accurately and signed by both the patient and a physician. This is essential for the order to be legally valid.
  • Visibility: Keep the DNR order in an easily accessible location, such as on your refrigerator or with your important medical documents. This way, emergency responders can find it quickly.
  • Regular Review: It’s important to review your DNR order periodically. Life circumstances and health conditions can change, and your preferences may need to be updated accordingly.

By following these guidelines, you can ensure that your healthcare wishes are honored when it matters most.

Other Common State-specific Do Not Resuscitate Order Templates

How Old Do You Have to Be to Get a Dnr - Promotes understanding of the implications of a no-resuscitation wish.

In addition to its importance in defining the internal workings of an LLC, the New York Operating Agreement form can be easily accessed online, making it convenient for business owners to ensure compliance and clarity in their agreements. For those looking for a comprehensive resource, visit https://nyforms.com/operating-agreement-template for a useful template.

Whats Dnr - Patients should be aware that a DNR does not impact the care they receive prior to a cardiac or respiratory event.

Instructions on How to Fill Out New Jersey Do Not Resuscitate Order

Filling out the New Jersey Do Not Resuscitate Order (DNR) form is an important step in expressing your healthcare preferences. This document allows individuals to communicate their wishes regarding resuscitation in the event of a medical emergency. To ensure that the form is completed correctly, follow these steps carefully.

  1. Obtain the New Jersey DNR Order form. You can download it from the New Jersey Department of Health website or request a physical copy from your healthcare provider.
  2. Read the instructions on the form thoroughly. Familiarize yourself with the information required and the implications of your choices.
  3. Fill in your personal information. This includes your full name, date of birth, and address. Ensure that this information is accurate to avoid any confusion.
  4. Designate a healthcare representative if desired. You may choose someone to make decisions on your behalf. Include their name and contact information on the form.
  5. Indicate your preferences regarding resuscitation. Clearly mark your choice about whether you want resuscitation efforts to be made or not.
  6. Sign and date the form. Your signature is essential for the validity of the DNR order. If someone else is signing on your behalf, ensure that they provide their relationship to you.
  7. Have the form witnessed. New Jersey law requires that the DNR form be signed by two witnesses who are not related to you and who do not stand to gain from your death.
  8. Make copies of the completed form. Keep one copy for your records and provide copies to your healthcare provider and any family members involved in your care.

Once you have completed the form, it is crucial to discuss your wishes with your healthcare provider. They can help ensure that your preferences are documented in your medical records and understood by your care team.