Louisiana Do Not Resuscitate Order Template
This document serves as a Do Not Resuscitate (DNR) Order in accordance with the relevant state-specific regulations found in the Louisiana Revised Statutes. By completing this form, the individual indicated below directs health care providers to withhold cardiopulmonary resuscitation (CPR) in the event of a cardiac or respiratory arrest.
Please complete the following information to validate this DNR Order:
Patient Information:
- Name: ____________________________
- Date of Birth: ____________________
- Address: __________________________
- City: _____________________, State: Louisiana, Zip Code: ________
- Phone Number: _____________________
DNR Order:
I, ____________________________, being of sound mind and body, hereby direct any and all healthcare providers, in the event of my cardiac or respiratory arrest, to withhold cardiopulmonary resuscitation (CPR), including but not limited to mechanical respiration, advanced airway management, and artificial circulation. I understand the full implications of this order as indicated by my signature below.
Witness Information:
This DNR Order must be witnessed by two individuals who affirm that the patient is of sound mind and acting voluntarily.
- Witness 1 Name: _________________________
- Witness 1 Signature: ______________________ Date: _________
- Witness 2 Name: _________________________
- Witness 2 Signature: ______________________ Date: _________
Signature of Individual (or Legal Representative) Requesting DNR Order:
Signature: ____________________________ Date: _________
If signed by a legal representative, specify relationship: _________________________
This document must be reviewed periodically and presented to the attending physician or healthcare provider. The absence of this properly completed order may result in the administration of CPR in an emergency situation.
Physician Information:
- Physician Name: ____________________________
- License Number: ___________________________
- Phone Number: _____________________________
- Signature: _________________________________ Date: _________
By signing this document, the attending physician acknowledges the patient's directive and agrees that the instructions will be followed.
