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

A Do Not Resuscitate (DNR) Order is a legal document that allows an individual to express their wish not to receive cardiopulmonary resuscitation (CPR) in the event of a cardiac arrest or respiratory failure. This form is particularly important for those who have specific health conditions or who wish to avoid aggressive medical interventions at the end of life. Understanding the DNR Order in New York can provide clarity and peace of mind for individuals and their families during difficult times.

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Similar forms

Living Will: This document outlines a person's preferences regarding medical treatment in situations where they cannot communicate their wishes. Like a DNR, it focuses on end-of-life care and may include instructions about life-sustaining treatments.
Durable Power of Attorney for Health Care: This legal document allows an individual to appoint someone to make medical decisions on their behalf if they are unable to do so. It often complements a DNR by providing a designated advocate for health care choices.
NYCERS F266 Form: The nyforms.com/nycers-f266-template is vital for Tier 3 and Tier 4 vested members of the New York City Employees' Retirement System, allowing them to initiate payment of their Vested Retirement Benefit and formalize their beneficiary nominations.
Health Care Proxy: Similar to a durable power of attorney, a health care proxy designates a person to make medical decisions. It is specifically focused on health care and can guide actions in line with the patient's wishes, including those expressed in a DNR.
Physician Orders for Life-Sustaining Treatment (POLST): This form translates a patient's preferences regarding life-sustaining treatments into actionable medical orders. It is often used in conjunction with a DNR to provide clear instructions for emergency personnel.
Advance Directive: This broader category includes documents like living wills and durable powers of attorney. An advance directive communicates a person’s wishes regarding medical treatment and end-of-life care, similar to a DNR.
Do Not Intubate Order: This specific medical order indicates that a patient should not be placed on a ventilator if they stop breathing. It is closely related to a DNR, as both documents express a desire to limit aggressive medical interventions.

Document Sample

New York Do Not Resuscitate (DNR) Order Template

This Do Not Resuscitate Order (DNR) is made in accordance with New York State laws regarding medical orders.

By signing below, I am expressing my wishes with respect to resuscitation efforts in the event of my cardiac or respiratory arrest.

Patient Information:

Name: __________________________
Date of Birth: ___________________
Address: ________________________
City: ____________________________
State: __________________________
Zip Code: _______________________

Healthcare Provider Information:

Provider Name: ____________________
Provider Phone: ___________________
Provider Address: _________________

Patient's Wishes:

The patient does not wish to receive resuscitative measures in the event of:

Cardiac arrest
Respiratory arrest

Additional Instructions (if any):

___________________________________________________________

Signatures:

Patient's Signature: _________________________ Date: _______________

Healthcare Provider's Signature: _________________ Date: _______________

This document must be kept in a safe place and should be readily available to healthcare providers in the event of a medical emergency.

Download Do Not Resuscitate Order PDF

Key takeaways

When filling out and using the New York Do Not Resuscitate Order form, consider the following key takeaways:

Ensure that the form is completed in accordance with New York state guidelines. This includes providing all required information accurately.
Consult with your healthcare provider before finalizing the form. Their input can help clarify your wishes and ensure that the document is properly understood.
Make copies of the completed form. Distribute these copies to your healthcare team, family members, and anyone else involved in your care.
Review the form regularly. Changes in your health or personal preferences may necessitate updates to your Do Not Resuscitate Order.
Keep the original form in a visible and accessible location. Emergency responders and healthcare professionals need to find it quickly if necessary.

Other Common State-specific Do Not Resuscitate Order Templates

Whats Dnr - Individuals might also seek legal advice to ensure their DNR is valid and properly executed.

In order to successfully create a corporation in New York, it's imperative to complete the New York Articles of Incorporation form, which details the corporation's name, purpose, and structure. For an easy and efficient way to access this essential document, you can use Fillable Forms, ensuring that all the necessary information is accurately provided and compliant with state regulations.

How Old Do You Have to Be to Get a Dnr - A means to prevent unnecessary suffering in a medical crisis.

Dnr Document - This order does not affect the patient's right to pain relief or comfort measures.

What Does Dnr Mean - Completing a DNR Order involves discussions with healthcare providers about the benefits and risks of resuscitation.

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

Completing the New York Do Not Resuscitate Order form is a critical step for individuals who wish to express their preferences regarding resuscitation efforts in medical emergencies. This process requires careful consideration and attention to detail. Below are the steps to successfully fill out the form.

Obtain the New York Do Not Resuscitate Order form. This can typically be found online or through healthcare providers.
Read the instructions included with the form to ensure a clear understanding of the requirements.
Fill in your personal information, including your full name, date of birth, and address, in the designated sections.
Indicate the date on which you are completing the form.
Choose a healthcare proxy, if applicable, by providing their name and contact information. This person will be responsible for making decisions on your behalf.
Sign the form in the appropriate section. This signature confirms your wishes regarding resuscitation.
Have the form witnessed by two individuals who are not related to you and who do not stand to gain from your estate. They must sign the form as witnesses.
Make copies of the completed form for your records and to share with your healthcare provider and family members.

After completing these steps, the form should be stored in a safe yet accessible location. It is advisable to discuss your wishes with family and healthcare providers to ensure that everyone understands your preferences.