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Blank Do Not Resuscitate Order Template for New York

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The New York Do Not Resuscitate (DNR) Order form is a crucial document for individuals who wish to express their preferences regarding medical treatment in emergency situations. This form allows patients to communicate their desire not to receive cardiopulmonary resuscitation (CPR) in the event of cardiac arrest or respiratory failure. It is designed to ensure that healthcare providers respect the wishes of patients, particularly those with terminal illnesses or severe medical conditions. The DNR Order must be signed by both the patient and a physician, confirming that the patient understands the implications of their decision. Additionally, it is important for individuals to discuss their choices with family members and healthcare professionals to ensure that everyone is aware of their wishes. Proper completion and visibility of the form can provide peace of mind, knowing that one’s preferences will be honored during critical moments. Understanding the nuances of the DNR Order form can empower individuals to make informed decisions about their end-of-life care.

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Discover Other Common Do Not Resuscitate Order Forms for Specific States

Out of Hospital Dnr - Friends and family should be aware of your DNR status to honor your wishes.

Illinois Do Not Resuscitate Law - Some hospitals have specific protocols regarding DNR orders.

Steps to Using New York Do Not Resuscitate Order

Filling out the New York Do Not Resuscitate Order form requires careful attention to detail. This document serves as a directive regarding medical treatment preferences in emergency situations. It is essential to ensure that all sections are completed accurately to reflect the individual's wishes.

  1. Obtain the New York Do Not Resuscitate Order form from a healthcare provider or download it from the New York State Department of Health website.
  2. Fill in the patient's full name, date of birth, and address in the designated areas at the top of the form.
  3. Indicate the patient's medical condition and explain the reasons for requesting a Do Not Resuscitate Order in the provided section.
  4. Have the form signed by the patient or their legal representative. If the patient is unable to sign, a legal representative must do so on their behalf.
  5. Ensure that the form is dated at the time of signing.
  6. Have the form signed by a physician. The physician must be licensed to practice medicine in New York State.
  7. Make copies of the completed form for the patient, their healthcare proxy, and the physician.
  8. Provide a copy of the form to the patient's primary healthcare provider and any medical facility where the patient may receive care.

Once the form is completed and distributed, it is advisable to keep a copy in a readily accessible location. Regularly review the document to ensure it remains aligned with the patient's current wishes and medical condition.

Key takeaways

Filling out a Do Not Resuscitate (DNR) Order in New York is an important decision that requires careful consideration. Here are some key takeaways to help you understand the process and implications of this form.

  • The DNR Order is a legal document that instructs medical personnel not to perform cardiopulmonary resuscitation (CPR) in the event of cardiac arrest.
  • It is essential to have a conversation with your healthcare provider about your wishes before completing the form.
  • The DNR Order must be signed by a physician, which ensures that it is valid and recognized by medical staff.
  • Once signed, the DNR Order should be kept in an accessible location, such as on the refrigerator or with other important medical documents.
  • Family members and caregivers should be informed about the existence of the DNR Order to avoid confusion during a medical emergency.
  • In New York, the DNR Order is recognized across all healthcare settings, including hospitals, nursing homes, and at home.
  • It is important to review and update the DNR Order periodically, especially if there are changes in your health status or treatment preferences.
  • Having a DNR Order does not affect the quality of care you receive; it simply outlines your wishes regarding resuscitation efforts.

Understanding these points can help ensure that your healthcare preferences are respected and that you receive care aligned with your values and wishes.

Misconceptions

Many people have misunderstandings about the New York Do Not Resuscitate (DNR) Order form. Here are nine common misconceptions, along with explanations to clarify each one.

  1. A DNR means I will not receive any medical treatment.

    This is incorrect. A DNR specifically refers to not performing CPR or advanced life-saving measures if your heart stops or you stop breathing. Other medical treatments can still be provided.

  2. I can only have a DNR if I am terminally ill.

    This is a misconception. While many people with terminal illnesses choose to have a DNR, anyone can request one, regardless of their health status.

  3. A DNR is the same as a living will.

    These are different documents. A living will outlines your wishes regarding medical treatment in various situations, while a DNR specifically addresses resuscitation efforts.

  4. This is not true. You do not need a lawyer to fill out a DNR form. However, it is wise to discuss your wishes with your healthcare provider.

  5. This is a misconception. A DNR can be established for use in any healthcare setting, including at home or in a nursing facility.

  6. Once a DNR is properly executed, it reflects your wishes. Family members cannot override it unless you have given them legal authority to do so.

  7. This is true. You can revoke or change your DNR order whenever you wish, as long as you communicate your decision clearly.

  8. This is a misconception. People of all ages can have DNR orders based on their personal health care preferences.

  9. While it is important to have the form accessible, it is not mandatory to carry it everywhere. Having it in your medical records or with your healthcare provider is often sufficient.

Preview - New York Do Not Resuscitate Order Form

New York Do Not Resuscitate Order (DNR)

This Do Not Resuscitate Order (DNR) is created in accordance with New York State law. This document expresses the wish to forgo resuscitation in the event of cardiac arrest or complete cessation of breathing. It is important to make your preferences known to ensure that they are honored in emergency situations.

Patient Information:

  • Full Name: ______________________________
  • Date of Birth: _________________________
  • Address: ______________________________
  • City/State/Zip: ________________________
  • Phone Number: _________________________

Physician Information:

  • Physician's Name: ______________________
  • Practice Name: ________________________
  • Address: ______________________________
  • Phone Number: _________________________

Statement of Patient's Wishes:

I, ______________________________, hereby declare my wishes regarding resuscitation. In the event that my heart stops beating or I stop breathing, I do not wish to have cardiopulmonary resuscitation (CPR) performed. This decision has been made after thorough discussion with my healthcare provider.

Signature of Patient: ___________________________

Date: ___________________________

Signature of Physician: _________________________

Date: ___________________________

This DNR is valid until revoked by the patient. It is recommended to keep this document in a prominent place and share copies with trusted family members, healthcare providers, and emergency contacts.

Next of Kin/Legal Representative (optional):

  • Name: ______________________________
  • Relationship: ________________________
  • Phone Number: ________________________

PDF Form Specifics

Fact Name Description
Definition The New York Do Not Resuscitate Order (DNR) form is a legal document that instructs medical personnel not to perform cardiopulmonary resuscitation (CPR) in the event of cardiac arrest.
Governing Law The New York DNR form is governed by Public Health Law § 2967 and § 2994-d.
Eligibility Individuals who are 18 years or older and have the capacity to make their own medical decisions can complete a DNR order.
Signature Requirements The form must be signed by the patient or their legal representative, along with a physician's signature.
Validity The DNR order remains valid until it is revoked by the patient or their representative or until the patient’s death.
Notification Healthcare providers must be notified of the existence of the DNR order and have access to the signed form.
Emergency Medical Services Emergency medical services personnel are required to honor a valid DNR order in the field.
Form Availability The New York DNR form can be obtained from healthcare providers, hospitals, or online from state health department resources.