Content Overview
Form Breakdown
| Fact Name | Description |
|---|---|
| Purpose | The California Do Not Resuscitate (DNR) Order form allows individuals to refuse resuscitation in case of a medical emergency. |
| Governing Law | This form is governed by California Health and Safety Code Section 7180-7190. |
| Eligibility | Any adult who is capable of making medical decisions can complete a DNR order. |
| Signature Requirement | The form must be signed by the individual or their legal representative. |
| Healthcare Provider's Role | A physician must sign the DNR order for it to be valid. |
| Where to Keep It | The completed DNR order should be kept in a place that is easily accessible to emergency responders. |
| Revocation | Individuals can revoke the DNR order at any time, verbally or in writing. |
| Emergency Services | Emergency medical personnel are required to honor a valid DNR order. |
| Additional Documentation | It is recommended to inform family members and healthcare providers about the DNR order. |
Sample - California Do Not Resuscitate Order Form
California Do Not Resuscitate Order
This Do Not Resuscitate (DNR) Order is a legally recognized document in the State of California, created according to California Health and Safety Code Section 7180-7190. It expresses the individual’s wishes regarding resuscitative measures in the event of a medical emergency.
Please fill out your information in the spaces provided below:
- Patient's Full Name: _______________________________
- Date of Birth: _______________________________
- Address: _______________________________
- City, State, ZIP: _______________________________
- Emergency Contact Name: _______________________________
- Emergency Contact Phone Number: _______________________________
Statement of Wishes:
I, _______________________________, hereby declare that I do not wish to receive resuscitation attempts in the event of cardiac arrest or respiratory failure. I have discussed this decision with my physician, _______________________________, who has agreed to respect my wishes.
Signature of Patient: _______________________________
Date: _______________________________
Witness Statement:
This statement is valid only if signed by two witnesses who are not directly involved in the patient's medical care or are not related to the patient.
- Witness 1 Name: _______________________________
- Witness 1 Signature: _______________________________
- Date: _______________________________
- Witness 2 Name: _______________________________
- Witness 2 Signature: _______________________________
- Date: _______________________________
This document must be presented to healthcare providers and kept in a safe and accessible place. It is recommended to share copies with family members and your healthcare proxy.
Common mistakes
Completing a California Do Not Resuscitate (DNR) Order form is a critical step for individuals wishing to express their medical care preferences. However, many people make mistakes that can lead to confusion or invalidation of their wishes. Understanding these common pitfalls is essential for ensuring that the form is filled out correctly.
One significant mistake is failing to sign the form. The DNR Order requires the signature of the individual or their authorized representative. Without a signature, the form cannot be recognized by medical personnel, rendering it ineffective. It is crucial to ensure that this step is not overlooked.
Another frequent error involves not dating the form. A DNR Order must include the date it was signed to establish its validity. If the date is missing, healthcare providers may question the authenticity of the document, leading to potential delays in honoring the individual’s wishes.
Inaccurate personal information is also a common issue. Individuals should double-check that their name, address, and date of birth are correctly entered. Errors in personal details can create confusion and may result in the form being disregarded during a medical emergency.
Some people neglect to discuss their DNR wishes with family members or healthcare providers. This lack of communication can lead to misunderstandings or disagreements when the time comes to implement the DNR Order. It is vital to ensure that loved ones and medical professionals are aware of the individual’s wishes to avoid unnecessary stress during critical moments.
Another mistake is not reviewing the form after it has been completed. Changes in health status or personal preferences may necessitate updates to the DNR Order. Regularly reviewing the document ensures that it reflects current wishes and remains valid.
Additionally, individuals often forget to provide copies of the DNR Order to their healthcare providers. Having copies on file ensures that medical personnel are aware of the individual’s preferences and can act accordingly in an emergency situation. Providing copies to hospitals, doctors, and family members is an important step in the process.
Lastly, some individuals may use outdated versions of the DNR form. It is crucial to use the most current form available to ensure compliance with California laws. Outdated forms may not be recognized, leading to complications in honoring the individual's wishes.
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