Fillable Maryland Do Not Resuscitate Order Template
In Maryland, the Do Not Resuscitate (DNR) Order form serves as a critical document for individuals who wish to make their end-of-life care preferences clear. This form allows patients to communicate their wishes regarding resuscitation efforts in the event of a medical emergency. It is designed for use by adults who are facing serious illness or those who wish to avoid aggressive medical interventions. The DNR form must be completed and signed by a physician, ensuring that medical professionals are aware of the patient's desires. Additionally, it requires the signature of the patient or their legal representative, further solidifying the patient's autonomy in making healthcare decisions. Understanding the nuances of this form is essential for anyone considering their options for medical care, as it not only addresses resuscitation but also reflects the values and wishes of the individual regarding their treatment in critical situations.
Maryland Do Not Resuscitate Order Preview
Maryland Do Not Resuscitate (DNR) Order
This document serves as a legal Do Not Resuscitate (DNR) Order under the health care laws of the State of Maryland, specifically referencing the Maryland Health Care Decisions Act. It is designed to inform health care providers of the undersigned's wishes not to receive cardiopulmonary resuscitation (CPR) in the event the undersigned's heart stops beating or the undersigned stops breathing. Please complete all the necessary fields to ensure the document reflects your wishes accurately.
Patient Information
Patient Name: ___________________________________________________________
Address: __________________________________________________________________
Date of Birth: ____________________________________________________________
Phone Number: ____________________________________________________________
Do Not Resuscitate (DNR) Order
I, the undersigned, being of sound mind, hereby direct that no resuscitation efforts, including CPR, be initiated or continued if my heart and breathing cease. This decision is made in accordance with Maryland state law and is to be followed by any and all health care providers, whether in a hospital, at my home, or elsewhere. This DNR Order is made knowing the consequences it entails.
By signing this document, I understand that this order does not affect the provision of other emergency procedures, such as airway management, pain relief, and the application of necessary medications or treatments to provide comfort care or ease pain.
Signature
Patient or Legal Guardian Signature: ________________________________________
Date: ____________________________________________________________________
Physician Information and Acknowledgment
The undersigned certifies that the individual, or their legal guardian, has discussed the contents of this DNR Order and is fully informed of its significance.
Physician's Name: _________________________________________________________
License Number: __________________________________________________________
Address: __________________________________________________________________
Phone Number: ____________________________________________________________
Physician Signature: ______________________________________________________
Date: _____________________________________________________________________
Instructions for Use
Keep this document in a prominent and accessible location. Inform family members, close friends, and your health care proxy, if applicable, of its existence and location. Present this DNR Order to your doctor to be included in your medical records. It is also advisable to carry a note or card in your wallet indicating that you have a DNR order in place.
Revocation of DNR Order
This DNR Order remains in effect until it is revoked. To revoke, you may destroy the DNR order, create a new health directive, or verbally inform your physician of your wish to revoke this order.
Form Specifications
| Fact Name | Description |
|---|---|
| Definition | The Maryland Do Not Resuscitate (DNR) Order is a legal document that allows a person to refuse resuscitation efforts in case of cardiac or respiratory arrest. |
| Governing Law | The Maryland DNR Order is governed by the Maryland Health-General Article, § 5-605. |
| Eligibility | Any adult can complete a DNR Order if they wish to refuse resuscitation efforts. |
| Signature Requirement | The DNR Order must be signed by the patient or their legal representative. |
| Witness Requirement | The signature of the patient or representative must be witnessed by two adults who are not related to the patient. |
| Healthcare Provider Role | A healthcare provider must sign the DNR Order for it to be valid and recognized in medical settings. |
| Revocation | A DNR Order can be revoked at any time by the patient or their legal representative. |
| Emergency Medical Services | Emergency medical services must honor a valid DNR Order when responding to a medical emergency. |
| Form Availability | The Maryland DNR Order form is available through healthcare providers and state health department resources. |
| Documentation | It is important to keep a copy of the DNR Order in a visible location, such as on the refrigerator or in a medical file. |
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