Rhode Island Do Not Resuscitate (DNR) Order Template
This document serves as a Do Not Resuscitate (DNR) Order in accordance with the relevant Rhode Island General Laws. It signifies the individual's decision to decline resuscitation attempts in the event of cardiac or respiratory arrest. This template is designed to ensure the wishes of the individual are known and respected by healthcare providers. Please ensure all sections are completed accurately.
Personal Information:
- Full Name: _______________________________________
- Date of Birth: ____________________________________
- Address: __________________________________________
- City: ___________________ State: RI Zip Code: ________
Medical Information:
- Primary Physician's Name: ____________________________
- Physician's Phone Number: ____________________________
- Medical Condition leading to DNR Order: _______________
By signing this document, I _____________ [insert name], understand and agree that in the event of a cardiac or respiratory arrest, medical personnel shall not initiate cardiopulmonary resuscitation (CPR) or other life-sustaining measures.
I acknowledge that this decision will not affect the provision of other emergency care, including oxygen, pain relief, and comfort care. I have discussed my choices with my physician, who has explained the nature and consequences of a DNR order.
This DNR order is made voluntarily and without any external pressure. It is based on my informed consent and understanding of my medical condition and treatment options.
Signature: ________________________________________ Date: ______________
Primary Physician's Signature*: ____________________ Date: ______________
*Physician's signature confirms the patient's informed decision and medical advisability of the DNR order.
Witness Information (if applicable):
This section to be completed if the order is signed by a legal representative or healthcare proxy on behalf of the patient.
- Witness Name: ________________________________________
- Relation to Patient: _________________________________
- Signature: ___________________________________________ Date: ____________
For use in the State of Rhode Island only. This template should be reviewed and kept on file by the patient’s primary physician and included in any medical records or charts to ensure the DNR order is respected across all healthcare settings.