New Jersey Do Not Resuscitate Order (DNR)
This Do Not Resuscitate Order (DNR) is executed in accordance with New Jersey state law regarding end-of-life care and medical decision-making. It is essential for individuals wishing to express their preferences regarding resuscitation efforts in medical emergencies.
Patient Information:
- Patient Name: ___________________________________
- Date of Birth: ________________________________
- Address: _______________________________________
- Phone Number: ________________________________
Medical Directive:
I, the undersigned, voluntarily and of my own free will, hereby declare that I do not wish to have cardiopulmonary resuscitation (CPR) or other resuscitative measures administered to me in the event of a cardiac arrest or respiratory failure.
Effective Date:
- Date of Implementation: ______________________
Healthcare Provider(s):
- Primary Physician: ___________________________
- Phone Number: ________________________________
This order remains valid unless revoked or altered. Family members and healthcare providers should be informed of its existence.
Signatures:
- Patient’s Signature: ___________________________
- Date: ______________________________________
- Witness Signature: ___________________________
- Date: ______________________________________
By signing this document, I acknowledge that I understand my rights regarding this Do Not Resuscitate Order and the implications of withholding resuscitative measures.
Let this document serve as a guide for my medical care preferences.