OKLAHOMA DONOTRESUSCITATE (DNR) CONSENT FORM I, , request limited health care as described in this document. If my heart stops beating or if I stop breathing, no medical procedure to restore breathing or heart function will be instituted by any health care provider including, but not limited to, emergency medical services (EMS) personnel. I understand that this decision will not prevent me from receiving other health care such as the Heimlich maneuver or oxygen and other comfort care measures. I understand that I may revoke this consent at any time in one of the following ways: 1. If I am under the care of a health care agency, by making an oral, written, or other act of communication to a physician or other health care provider of a health care agency; 2. If I am not under the care of a health care agency, by destroying my donot resuscitate form, removing all donotresuscitate identification from my person, and notifying my attending physician of the revocation; 3. If I am incapacitated and under the care of a health care agency, my representative may revoke the donotresuscitate consent by written notification to a physician or other health care provider of the health care agency or by oral notification to my attending physician; or 4. If I am incapacitated and not under the care of a health care agency, my representative may revoke the donotresuscitate consent by destroying the donotresuscitate form, removing all donotresuscitate identification from my person, and notifying my attending physician of the revocation. I give permission for this information to be given to EMS personnel, doctors, nurses, and other health care providers. I hereby state that I am making an informed decision and agree to a donotresuscitate order. Signature of Person Date or Signature of Representative (Limited to an attorneyinfact for health care decisions acting under the Durable Power of Attorney Act, a health care proxy acting under the Oklahoma Advance Directive Act or a guardian of the person appointed under the Oklahoma Guardianship and Conservatorship Act.) This DNR consent form was signed in my presence. Signature of Witness Address Signature of Witness Address CERTIFICATION OF PHYSICIAN This form is to be used by an attending physician only to certify that an incapacitated person without a representative would not have consented to the administration of cardiopulmonary resuscitation in the event of cardiac or respiratory arrest. An attending physician of an incapacitated person without a representative must know by clear and convincing evidence that the incapacitated person, when competent, decided on the basis of information sufficient to constitute informed consent that such person would not have consented to the administration of cardiopulmonary resuscitation in the event of cardiac or respiratory arrest. Clear and convincing evidence for this purpose shall include oral, written, or other acts of communication between the patient, when competent, and family members, health care providers, or others close to the patient with knowledge of the patient’s desires. I hereby certify, based on clear and convincing evidence presented to me, that I believe that Name of Incapacitated Person would not have consented to the administration of cardiopulmonary resuscitation in the event of cardiac or respiratory arrest. Therefore, in the event of cardiac or respiratory arrest, no chest compressions, artificial ventilation, intubations, defibrillation, or emergency cardiac medications are to be initiated. Physician’s Signature Physician’s Name (PRINT) Physician’s Address/Phone Date This DNR consent form and Certification of Physician is copied from Senate Bill 1325. This law is effective November 1, 2010. This form is available online at: http://www.okdhs.org/divisionsoffices/visd/asd/ under Quick Links OKDHS Pub. No. 9720 Revised 11/2010 This publication is authorized by the Oklahoma Commission for Human Services in accordance with state and federal regulations and printed by the Oklahoma Department of Human Services at a cost of $90 for 1,610 copies. Copies have been deposited with the Publications Clearinghouse of the Oklahoma Department of Libraries. OKDHS offices may request copies on ADM9 (23AM009E) electronic supply orders. Members of the public may obtain copies by contacting OKDHS Design Services at 18772834113 (toll free), by faxing an order to (405) 9621740, or by downloading a copy at www.okdhs.org/pubs.
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