DO NOT RESUSCITATE (DNR)

WITHHOLD/WITHDRAW LIFE SUSTAINING TREATMENT ORDER

PATIENT’S NAME: _______________________________ AGE: ________ GENDER:_____________

CASE NUMBER: ________________________________ ATTENDING PHYSICIAN: ___________________

In case of Cardiopulmonary (CP) arrest, indicate the treatment to be withdrawn:

WITHHOLD/ SIGNATURE WITHDRAW/ SIGNATURE

Resuscitation (CPR)

Defibrillation

Intubation and Mechanical

Ventilation

Artificial Hydration and Nutrition

Medications

Other Instructions/ Specific Orders:

_______________________________________________________________________________________________________
___________________________________________________________________________________
Rationale:

( ) Terminally Ill ( ) Immediately Dying

( ) Chronic Coma ( ) Prior legal directive arrangements

( ) Patient (or relative) determination that burden outweighs the benefits

Patient’s mental capacity: ( ) capable ( )incapacitated

I,______(name)_________________,_____(age)_______,of___________(address)__________________fully understand
the above request and have discussed with the family/representative and consent to the withholding/withdrawal of the treatment
in the aforementioned checklist.

____________________________________
Printed name and Signature/Relation to Patient

Witnesses:
1. ______________________
2. ______________________
CHECKLIST FOR DNR

Yes No

1. Indications for DNR present

2. Written order of physician

3. Properly signed informed consent

4. Verification of next of kin

5. Present during conference:

5.1. Members of the Family

5.2. Attending Physician

REVOCATION
DO NOT RESUSCITATE (DNR)
WITHHOLD/WITHDRAW LIFE SUSTAINING TREATMENT ORDER

After thoroughly discussing the situation with the patient/family members/ representative, the DNR/Withhold/Withdraw
Life Sustaining Treatment Order of patient _____________________________________ is hereby withdrawn and cancelled.
Date and time: _________________

____________________________________
Printed name and Signature/Relation to Patient
Witnesses:
1. ______________________
2. ______________________