Tennessee Do Not Resuscitate Form

CPR
STATE OF TENNESSEE
EMERGENCY MEDICAL SERVICES
DO NOT RESUSCITATE (DNR)
ORDER
Patient’s Full Name
ATTENDING PHYSICIAN’S STATEMENT
I am the attending physician of the patient named above and direct medical personnel not initiate cardiopulmonary
resuscitation on this patient. I understand that I may revoke these directions at any time.
Date
signature of Attending Physician
PRINTED NAME OF ATTENDING PHYSICIAN
THIS ORDER REMAINS IN EFFECT UNTIL THE DEATH OF THE
PATIENT OR THE DOCUMENT IS DESTROYED
PATIENT’S STATEMENT
I, the undersigned patient, or agent with a durable power of attorney for health care, direct that cardiopulmonary
resuscitation should not be initiated. I understand that I may revoke these directions at any time.
Signature of Witness
Signature of Patient
Printed Name of Witness
Printed Full Name of Patient
Date
Signature of DPAH/C
Printed Full Name of Person Acting with durable
power of attorney for health care
THIS FORM WILL ACCOMPANY THE PATIENT DURING AMBULANCE TRANSPORT
A photostatic copy of the original, properly executed form may serve as a legal DNR order pursuant to Tennessee Code
Annotated § 68-140-602(1)
In the event of the patient’s death, the EMS agency on the scene shall obtain this form and it shall become part of the
EMS Medical Record.
Permission is hereby granted to reprint blank copies of this form for use by patients and physicians. Such copies must
include the complete and original text of both sides of the form with no additions or deletions.
PH-3338 (Rev. 7-96)
RDA N/A
EXPLANATION TO THE PATIENT AND FAMILY
The patient and family:
Understand that the patient has been diagnosed with a terminal medical condition.
Recognizes the physician identified on this form as the attending physician with primary patient care
responsibilities.
Understands that supportive care will be provided to the patient.
Arranges for placement of the DNR document near the bedside of the patient in a location that is made known to
everyone involved in the care of the patient.
Understands that EMS assistance may not be required under local guidelines and has discussed when it is or not
appropriate to call the EMS system for assistance and transport.
PHYSICIAN RESPONSIBILITIES
In accordance with the guidelines for a Do-Not-Resuscitate Order the attending physician:
Has determined that the patient is in a terminal condition.
Has completed a DNR form that identifies the patient and recognizes the patient’s wishes for withholding
resuscitation.
Has discussed with the family and care givers procedures that are appropriate near the time of death, including
the need for EMS assistance and transport, palliative and supportive care; discontinuance or withholding of
resuscitative measures.
EMS PERSONNEL RESPONSIBILITIES
The Emergency Medical Personnel attending:
Will confirm the presence of the DNR order and the patient’s identity.
Will provide supportive and palliative care which includes:
Positioning the patient for comfort and airway control.
Suctioning of the airway.
Administration of oxygen.
Control of bleeding.
Splinting.
Administration of medication by advanced life support providers by orders through medical control.
Emotional support for the patient, family, and providers.
Will not initiate, administer or continue:
CPR
Chest Compressions.
Ventilatory Assistance.
Intubation-provided that existing tubes shall be allowed to remain in place.
Defibrillation or cardiac monitoring.
Cardiac resuscitation drugs.
Will notify medical control and the attending physician if stipulated by local protocols.
JP/G4119041-EMS
PH-3338 (Rev. 7-96)
RDA N/A