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Printable Do Not Resuscitate Order Form for the State of California

A Do Not Resuscitate (DNR) Order is a legal document that allows individuals to refuse cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest. In California, this form is crucial for ensuring that a person's wishes regarding end-of-life care are respected. Understanding how to properly complete and utilize this form is essential for anyone considering their medical options.

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Key takeaways

When filling out and using the California Do Not Resuscitate Order (DNR) form, it is essential to understand several key points. The following takeaways can help ensure the process is clear and effective.

The DNR form allows individuals to express their wishes regarding resuscitation efforts in case of a medical emergency.
It is crucial to complete the form accurately to reflect your preferences regarding life-saving measures.
Both the patient and their healthcare provider must sign the DNR form for it to be valid.
Make sure to discuss your decision with family members and healthcare professionals to ensure everyone understands your wishes.
The DNR order should be easily accessible to emergency medical personnel, so consider keeping a copy in a visible location.
Review the DNR order regularly, especially if there are changes in health status or personal preferences.
In California, the DNR form is recognized statewide, but it is advisable to check with local healthcare providers for any additional requirements.
Keep in mind that the DNR order only applies to resuscitation efforts and does not affect other medical treatments.

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Documents used along the form

When considering end-of-life care and medical decisions, various forms and documents can complement the California Do Not Resuscitate (DNR) Order. These documents help ensure that individuals' wishes are respected and understood by healthcare providers. Below is a list of important forms that may be used alongside a DNR order.

Advance Healthcare Directive: This document allows individuals to outline their preferences for medical treatment and appoint a healthcare agent to make decisions on their behalf if they become unable to do so.
Physician Orders for Life-Sustaining Treatment (POLST): The POLST form translates a patient’s wishes regarding life-sustaining treatments into actionable medical orders for healthcare professionals.
Living Will: A living will specifies what types of medical treatments a person wants or does not want in situations where they are unable to communicate their wishes.
California Non-compete Agreement: Understanding the limitations and nuances of this agreement is crucial, especially since All California Forms clarify which aspects are enforceable.
Healthcare Power of Attorney: This legal document designates someone to make healthcare decisions for an individual if they are incapacitated.
Organ Donation Consent: A form that indicates an individual's wishes regarding organ and tissue donation after death, often included in advance directives.
Do Not Intubate (DNI) Order: This order specifically instructs healthcare providers not to place a patient on a ventilator if they are unable to breathe independently.
Emergency Medical Services (EMS) DNR Form: This form is used by emergency medical personnel to recognize and honor a patient's DNR wishes during emergencies.
Patient Self-Determination Act (PSDA) Documentation: This document outlines a patient’s rights under the PSDA, ensuring they are informed about their options for medical treatment.
Medical Record Release Authorization: This form allows individuals to authorize the sharing of their medical records with specific individuals or organizations, facilitating informed decision-making.
Patient Advocate Form: This document designates a patient advocate who can help communicate and uphold a patient’s healthcare wishes in various situations.

Understanding these documents is essential for making informed healthcare decisions. They work together to ensure that a person's values and preferences are honored throughout their medical care journey.

Similar forms

Advance Healthcare Directive: This document allows individuals to outline their preferences for medical treatment in case they become unable to communicate. Like a DNR, it provides guidance to healthcare providers about the patient's wishes.
Living Will: A living will specifies what types of medical treatment a person does or does not want in situations where they cannot express their wishes. It serves a similar purpose to a DNR by addressing end-of-life care decisions.
Arizona Agent Form: This essential document ensures compliance for corporations and LLCs in Arizona, signifying the agent's acceptance of responsibilities on behalf of the entity. For further details, visit arizonapdf.com/.
Durable Power of Attorney for Healthcare: This document designates a person to make healthcare decisions on someone’s behalf if they are unable to do so. It complements a DNR by ensuring that someone trusted can advocate for the patient's wishes.
POLST (Physician Orders for Life-Sustaining Treatment): A POLST form translates a patient's treatment preferences into actionable medical orders. Like a DNR, it is intended for individuals with serious health conditions and ensures that their wishes are respected in emergencies.

Document Features

Fact Name	Description
Purpose	The California Do Not Resuscitate (DNR) Order form is designed to communicate a patient's wishes regarding resuscitation efforts in the event of cardiac or respiratory arrest.
Governing Law	This form is governed by California Health and Safety Code Section 7180 et seq., which outlines the legal framework for advance healthcare directives.
Eligibility	Any adult capable of making medical decisions can complete a DNR Order, ensuring their preferences are respected during medical emergencies.
Signature Requirement	The form must be signed by the patient or their legally authorized representative to be valid, affirming the individual's intent.
Healthcare Provider's Role	A physician must sign the DNR Order, confirming that the patient understands the implications of their decision.
Revocation	Patients can revoke a DNR Order at any time. This can be done verbally or by destroying the form, ensuring flexibility in their healthcare decisions.
Distribution	Once completed, the DNR Order should be shared with healthcare providers, family members, and kept in a place easily accessible in emergencies.
Emergency Medical Services (EMS)	Emergency responders are required to honor a valid DNR Order, which can prevent unwanted resuscitation efforts in critical situations.
Form Availability	The California DNR Order form can be obtained online or through healthcare facilities, making it accessible to those who need it.
Legal Protection	Healthcare providers and emergency responders are protected from liability when they follow a valid DNR Order, ensuring they act in accordance with the patient's wishes.

Some Other Do Not Resuscitate Order State Forms

What Does Do Not Resuscitate Mean - Considered a crucial element in respecting patient dignity during critical care decisions.

The Texas Motor Vehicle Bill of Sale form is a legal document used to record the sale and transfer of ownership of a vehicle in Texas. This form provides important information about the buyer, seller, and the vehicle itself, ensuring a clear record of the transaction. Using this form helps protect both parties by confirming the agreement reached during the sale. For more detailed information, you can visit documentonline.org/blank-texas-motor-vehicle-bill-of-sale/.

Do Not Resuscitate Guidelines - While a DNR may seem daunting, it acts to affirm the individual's wishes clearly and respectfully.

Do Not Resuscitate Form Michigan - A DNR order empowers patients to express their choices regarding life-sustaining treatments.

Common mistakes

Not discussing the decision with a healthcare provider. Many individuals fill out the Do Not Resuscitate Order (DNR) form without having a thorough conversation with their doctor. This can lead to misunderstandings about what a DNR means and the implications it has for medical care.
Failing to sign and date the form. A common oversight is neglecting to provide a signature and the date on the DNR form. Without these, the document may not be considered valid, potentially leading to unwanted resuscitation efforts.
Not sharing the form with relevant parties. After completing the DNR form, it is crucial to share copies with family members, healthcare providers, and any medical facilities where care might be received. If the form is not readily accessible, medical staff may not be aware of the patient’s wishes.
Using outdated versions of the form. Some individuals may mistakenly use an old version of the DNR form. It's important to ensure that the most current form is being used, as laws and regulations can change over time.
Not reviewing the form regularly. Life circumstances can change, and so can a person's wishes regarding resuscitation. Failing to review and update the DNR form periodically can lead to situations where the document no longer reflects the individual's current desires.

Preview - California Do Not Resuscitate Order Form

California Do Not Resuscitate Order

This California Do Not Resuscitate (DNR) Order is based on the California Family Code Section 4780-4787. Use this document to express your wishes regarding resuscitation efforts in the event of a medical emergency.

Please complete the information below:

Patient's Full Name: ________________________
Date of Birth: ________________________
Patient's Address: ________________________

Physician’s Statement:

Based on my professional assessment, I confirm that this patient is in a medical condition where resuscitation efforts may not be desired.

Physician's Name: ________________________

Physician's License Number: ________________________

Date: ________________________

Signature of Patient or Legal Representative:

By signing below, I acknowledge that I am the patient or have the authority to make this decision on behalf of the patient.

Signature: ________________________

Date: ________________________

This document should be kept with the patient's medical records. It is essential for healthcare providers to have easy access to this Order during emergencies.

If you have any questions regarding this form, consult with a medical professional or an attorney.