Valid Do Not Resuscitate Order Template for the State of Connecticut

Connecticut Do Not Resuscitate (DNR) Order Template

This document serves as a Do Not Resuscitate Order pursuant to the guidelines and regulations set forth by the State of Connecticut, specifically under the authority of the Connecticut Department of Public Health. It is intended to inform medical personnel that the individual named herein has chosen not to receive cardiopulmonary resuscitation (CPR) in the event that their breathing stops or if their heart stops beating.

Patient Information:

• Full Name: _________________________________________________________
• Date of Birth: __________________________
• Address: __________________________________________________________
• Primary Physician: __________________________________________________
• Physician Phone Number: ____________________________________________

Medical Information:

• Primary Diagnosis: _________________________________________________
• Allergies (if any): ________________________________________________
• Relevant Medical History: __________________________________________

This order is effective immediately and remains in effect until the individual revokes it or a physician determines that it should be cancelled.

Patient Consent:

I, ___________________________________ (patient name), hereby acknowledge that I fully understand the nature and purpose of this Do Not Resuscitate (DNR) Order. I have discussed my options with my physician and fully understand the implications of this decision. By signing this order, I am directing medical personnel to withhold cardiopulmonary resuscitation (CPR) or advanced cardiac life support (ACLS) in the event that my breathing or heart stops.

Signature: _________________________________ Date: __________________

Physician Consent:

I, ___________________________________ (physician name), certify that I have discussed the nature, implications, and consequences of a Do Not Resuscitate (DNR) Order with the above-named patient, or their legally authorized representative, and am satisfied that the patient/legal representative fully understands the meaning and importance of this document.

Signature: _________________________________ Date: __________________

Licence Number: _____________________________________________________

Instructions for Use:

1. This document must be completed and signed by both the patient (or their legally authorized representative) and the patient's physician.
2. Once completed and signed, the DNR Order should be posted in an easily visible and accessible location within the patient's residence, and a copy should be provided to the patient's primary care physician and any home health agencies involved in the patient's care.
3. In the event of an emergency, medical personnel should be informed of the DNR Order's existence and shown the document as soon as possible.
4. If the patient wishes to revoke the DNR Order at any time, they must inform their physician and all relevant healthcare providers in writing.