Louisiana Do Not Resuscitate Order Template
This Do Not Resuscitate (DNR) Order is established in accordance with Louisiana state laws regarding advance directives and end-of-life care. It is intended to communicate the wishes of the patient regarding resuscitation efforts in the event of a medical emergency.
Patient Information:
- Patient's Full Name: _______________________________
- Date of Birth: _______________________________
- Address: _______________________________
- City, State, Zip Code: _______________________________
Healthcare Proxy Information:
- Name of Healthcare Proxy: _______________________________
- Relationship to Patient: _______________________________
- Phone Number: _______________________________
Patient's Wishes:
The patient hereby expresses the wish to withhold resuscitation efforts in the event of cardiac or respiratory arrest. This order applies to all healthcare providers and must be honored in all settings, including emergency situations.
Signature:
- Patient's Signature: _______________________________
- Date: _______________________________
Witness Information:
- Witness 1 Name: _______________________________
- Witness 1 Signature: _______________________________
- Date: _______________________________
- Witness 2 Name: _______________________________
- Witness 2 Signature: _______________________________
- Date: _______________________________
This document serves as a formal declaration of the patient's desire regarding resuscitation. It is recommended that copies be provided to the patient's healthcare providers and family members.