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.
