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Get OHDNR Order 2007

OUTSIDE THE HOSPITAL DO-NOT-RESUSCITATE OHDNR ORDER I authorize emergency medical services personnel to name withhold or withdraw cardiopulmonary resuscitation from me in the event I suffer cardiac or respiratory arrest. Emergency Medical Services personnel shall not comply with an outside the hospital do-not-resuscitate order when the patient or the patient s representative expresses to such personnel in any manner before or after the onset of a cardiac or respiratory arrest the desire to be resuscitated or if the patient is or is believed to be pregnant. I hereby agree to the Outside The Hospital Do-Not-Resuscitate OHDNR Order. Patient Printed or Typed Name Date Patient s Signature or Patient Representative s Signature REVOCATION PROVISION I hereby revoke the above declaration. I AUTHORIZE EMERGENCY MEDICAL SERVICES PERSONNEL TO WITHHOLD OR WITHDRAW CARDIOPULMONARY RESUSCITATION FROM THE PATIENT IN THE EVENT OF CARDIAC OR RESPIRATORY ARREST. Cardiac arrest means my heart stops beating and respiratory arrest means I stop breathing. I understand that in the event that I suffer cardiac or respiratory arrest this OHDNR order will take effect and no medical procedure to restart breathing or heart functioning will be instituted* interventions such as intravenous fluids oxygen or therapies other than cardiopulmonary resuscitation such as those deemed necessary to provide comfort care or to alleviate pain by any health care provider e*g* paramedics and/or medical care directed by a physician prior to my death. I understand I may revoke this order at any time. I give permission for this OHDNR order to be given to outside the hospital care providers e*g* paramedics doctors nurses or other health care personnel as necessary to implement this order. I affirm this order is the expressed wish of the patient/patient s representative medically appropriate and documented in the patient s permanent medical record. Attending Physician s Signature Mandatory License No* Telephone No* Address Printed or Typed Facility or Agency Name THIS OHDNR ORDER SHALL REMAIN WITH THE PATIENT WHEN TRANSFERRED OUTSIDE THE HEALTH CARE FACILITY. Cardiac arrest means my heart stops beating and respiratory arrest means I stop breathing. I understand that in the event that I suffer cardiac or respiratory arrest this OHDNR order will take effect and no medical procedure to restart breathing or heart functioning will be instituted* interventions such as intravenous fluids oxygen or therapies other than cardiopulmonary resuscitation such as those deemed necessary to provide comfort care or to alleviate pain by any health care provider e*g* paramedics and/or medical care directed by a physician prior to my death. I understand I may revoke this order at any time. I give permission for this OHDNR order to be given to outside the hospital care providers e*g* paramedics doctors nurses or other health care personnel as necessary to implement this order. I affirm this order is the expressed wish of the patient/patient s representative medically appropriate and documented in the patient s permanent medical record. Attending Physician s Signature Mandatory License No* Telephone No* Address Printed or Typed Facility or Agency Name THIS OHDNR ORDER SHALL REMAIN WITH THE PATIENT WHEN TRANSFERRED OUTSIDE THE HEALTH CARE FACILITY. .

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