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Official Do Not Resuscitate Order Template for the State of North Carolina

A Do Not Resuscitate (DNR) Order form in North Carolina is a legal document that allows individuals to express their wishes regarding resuscitation efforts in the event of a medical emergency. This form is crucial for ensuring that healthcare providers respect a person's preferences when it comes to life-sustaining treatments. Understanding the implications and processes surrounding this form can help individuals make informed decisions about their healthcare choices.

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Similar forms

Advance Directive: This document outlines a person's preferences for medical treatment in situations where they cannot communicate their wishes. It serves a similar purpose to a Do Not Resuscitate Order by guiding healthcare providers in accordance with the patient's desires.
Living Will: A living will specifies the types of medical treatment a person wishes to receive or avoid in the event of terminal illness or incapacitation. Like a DNR, it focuses on end-of-life decisions.
Durable Power of Attorney for Healthcare: This document designates an individual to make healthcare decisions on behalf of another person. It complements a DNR by ensuring that someone can advocate for the patient's wishes if they are unable to do so themselves.
Physician Orders for Life-Sustaining Treatment (POLST): POLST is a medical order that specifies which treatments a patient wants or does not want in a medical emergency. It is similar to a DNR in that it communicates the patient's preferences directly to healthcare providers.
Medical Power of Attorney: This document allows an individual to appoint someone to make medical decisions on their behalf. It is related to a DNR as it ensures that a trusted person can enforce the patient's wishes regarding resuscitation.
Do Not Intubate Order: This order specifically instructs healthcare providers not to insert a breathing tube in the event of respiratory failure. It is similar to a DNR as both documents aim to limit aggressive medical interventions.
Power of Attorney: To grant financial and legal decision-making authority, consider the state-specific Power of Attorney guidelines designed to clarify expectations and responsibilities.
Comfort Care Order: A comfort care order focuses on providing relief from pain and distress without attempting to prolong life. This aligns with the intent of a DNR to prioritize quality of life over aggressive treatment.
End-of-Life Care Plan: This plan outlines the patient's wishes for care during their final days. It shares similarities with a DNR by addressing the type of care the patient desires as they approach death.
Organ Donation Consent Form: This document expresses a person's wishes regarding organ donation after death. While it serves a different purpose, both it and a DNR reflect the individual's preferences about medical treatment and end-of-life decisions.

Document Sample

North Carolina Do Not Resuscitate Order Template

This Do Not Resuscitate (DNR) order is established in accordance with North Carolina General Statutes, Chapter 90, Article 20, Section 90-21.17 and is intended to communicate a patient’s wishes regarding resuscitation in the event of cardiac or respiratory arrest.

Patient Information:

Patient Name: _______________________________
Date of Birth: _____________________________
Patient Address: ___________________________
City: _______________________________
State: _______________________________
Zip Code: _______________________________

This DNR order is issued voluntarily by the patient and reflects the following wishes:

The patient does not want cardiopulmonary resuscitation (CPR) or advanced cardiac life support (ACLS) if a cardiac or respiratory arrest occurs.
The patient has the capacity to make health care decisions and understands the implications of this order.
This order remains in effect until revoked in writing by the patient or their authorized representative.

Signature Section:

Patient's Signature: _______________________________
Date: _______________________________

Witness Information:

Witness Name: _______________________________
Witness Signature: _______________________________
Date: _______________________________

Physician Information:

Physician Name: _______________________________
Physician Signature: _______________________________
Date: _______________________________

The patient’s rights and all medical information shall remain confidential according to applicable state and federal laws.

Download Do Not Resuscitate Order PDF

Key takeaways

When considering the North Carolina Do Not Resuscitate (DNR) Order form, it's important to understand its purpose and how to use it effectively. Here are some key takeaways:

The DNR Order allows individuals to refuse resuscitation efforts in case of a medical emergency.
It is crucial to discuss your wishes with family members and healthcare providers before filling out the form.
The form must be signed by a physician to be valid; ensure you have a healthcare provider's agreement.
Once completed, keep the DNR Order in a visible place, such as on your refrigerator or with your medical records.
Inform emergency contacts about your DNR status so they can communicate your wishes if necessary.
The DNR Order can be revoked at any time, but it should be done in writing and communicated to your healthcare provider.
Review your DNR Order periodically to ensure it still reflects your current wishes and circumstances.

Other Common State-specific Do Not Resuscitate Order Templates

How Old Do You Have to Be to Get a Dnr - A compassionate choice for those facing terminal illness.

Polst Form Pdf - Can be provided to hospitals or emergency teams for easy access.

Whats Dnr - For patients in long-term care facilities, the DNR should be incorporated into their care plan for consistency and clarity.

The NYCERS F170 form serves as a vital tool for EMTs looking to take advantage of the optional 25-Year Retirement Program, ensuring that their years of dedicated service are recognized. For more details on this important document, you can visit https://nyforms.com/nycers-f170-template, where you’ll find additional information and resources to assist with the enrollment process.

How Old Do You Have to Be to Get a Dnr - The order can be revoked at any time if the patient changes their mind.

Instructions on How to Fill Out North Carolina Do Not Resuscitate Order

Filling out the North Carolina Do Not Resuscitate Order form is an important step for individuals who wish to express their medical preferences in advance. Once the form is completed, it should be shared with healthcare providers and kept in a readily accessible location. Here are the steps to guide you through the process of filling out the form.

Obtain the North Carolina Do Not Resuscitate Order form. You can find it online or request a copy from your healthcare provider.
Carefully read the instructions provided on the form to understand its purpose and implications.
Fill in your full name, date of birth, and any other identifying information requested on the form.
Indicate your wishes regarding resuscitation by checking the appropriate box. Make sure this reflects your true preferences.
Provide the name of your healthcare provider who will sign the form. This step is crucial for validating your wishes.
Sign and date the form to confirm that you understand and agree with the contents.
Have your healthcare provider sign the form to make it legally binding.
Make copies of the completed form for your records and distribute them to your healthcare providers, family members, and anyone else involved in your care.

Once you have completed these steps, ensure that the form is stored in a safe yet accessible place. It’s essential that your medical team and loved ones are aware of your wishes should the need arise.