Fillable Printable DNR Identification Form - Ohio

DNR Identification Form - Ohio

(Check only one box)

DNRCC (If this box is checked the DNR Comfort Care Protocol is activated immediately.)

DNRCC-Arrest (If this box is checked, the DNR Comfot Care Protocol is implemented in the event of a cardiac arrest or a respiratory arrest.)

Patient Name:

Address:

City: State: Zip:

Birthdate: Gender:

Signature: (optional)

DNR IDENTIFICATION FORM

M F

Do-Not-Resuscitate Order—My signature below constitutes

and conrms a formal order to emergency medical services and

other health care personnel that the person identied above is to be

treated under the State of Ohio DNR Protocol. I arm that this order

is not contrary to reasonable medical standards or, to the best of my

knowledge, contrary to the wishes of the person or of another person

who is lawfully authorized to make informed medical decisions on the

person’s behalf. I also arm that I have documented the grounds for

this order in the person’s medical record.

Living Will (Declaration) and Qualifying

Condition—The person identied above has a valid Ohio

Living Will (declaration) and has been certied by two physicians

in accordance with Ohio law as being terminal or in a permanent

unconscious state, or both.

Printed name of physician*:

Signature: Date:

Address: Phone:

City/State: Zip:

* A DNR order may be issued by a certified nurse practitioner, clinical nurse specialist, or a physician assistant when authorized by section 2133.211 of the Ohio Revised Code.

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3701-62-04

See reverse side for DNR Protocol

APPENDIX A

Certication of DNR Comfort Care Status

(to be completed by the physician)*

(Check only one box)

DO NOT RESUSCITATE COMFORT CARE PROTOCOL

3701-62-04

After the State of Ohio DNR Protocol has been activated for a specic DNR Comfort Care patient, the Protocol species that emergency medical services and other

health care workers are to do the following:

If you have responded to an emergency situation by initiating any of the WILL NOT actions prior to conrming that the DNR Comfort Care Protocol should be

activated, discontinue them when you activate the Protocol. You may continue respiratory assistance, IV medications, etc., that have been part of the

patient’s ongoing course of treatment for an underlying disease.

If family or bystanders request or demand resuscitation for a person for whom the DNR Comfort Care Protocol has been activated, do not proceed with

resuscitation. Provide comfort measures as outlined above and try to help the family members understand the dying process and the patient’s choice not to

be resuscitated.

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WILL:

• Suction the airway

• Administer oxygen

• Position for comfort

• Splint or immobilize

• Control bleeding

• Provide pain medication

• Provide emotional support

• Contact other appropriate health care providers, such as hospice, home

health, attending physicians, CNPs, and CNSs

WILL NOT:

• Administer chest compressions

• Insert articial air way

• Administer resuscitative drugs

• Debrillate or cardiovert

• Provide respiratory assistance (other than that listed above)

• Initiate resuscitative IV

• Initiate cardiac monitoring