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Mississippi Do Not Resuscitate (DNR) Order Form

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A patient may request a Mississippi do not resuscitate (DNR) order upon being admitted to any hospital in the State. This document directs the attending medical professionals to not resuscitate the patient if they have a cardiac or pulmonary arrest. The DNR order will be provided to the patient and filed in the patient’s medical record. For people in advanced stages of illness, the Mississippi Physician Orders for Sustaining Treatment (POST) Form further details what types of life-preserving and comfort measures should be permitted. This form can be obtained by a patient from their physician and will be kept in their medical record. The POST Form may be revoked at any time by the patient or their assigned health care decision maker.

Laws – § 41-41-301 – 41-41-303

Required to Sign – Patient (or representative), physician, and preparer (if applicable).

How to Write

Step 1 – Download the Mississippi POST Form (PDF Format).

Step 2 – Write the patient’s last name, first name, middle initial, and date of birth, along with the effective date of the form.

Step 3 – In Section A, the patient’s preference for CPR or DNR must be indicated by checking the appropriate box. Any section that is left unfilled will lead to a maximum intervention in that instance.

Step 4 – Next, one of the three (3) “Medical Interventions” options must be selected in order to indicate the level of treatment the patient is to receive. Enter any additional instructions in the provided spaces.

Step 5 – In Sections C and D, you must indicate whether antibiotics or medically administered fluid/nutrition will be allowed, and if so, for what duration (if at all).

Step 6 – Check the appropriate boxes to indicate if the patient has an advance healthcare directive and enter the “Date of Execution.” Below that, the patient or the person who is authorized to make health care decisions on their behalf must sign the form, print their name, and enter their relationship to the patient (enter “self” if patient). Next, check the appropriate boxes to indicate who the signatory is (see the next page for more options).

Step 7 – In Section F, you must supply the following:

  • Patient or representative’s signature, printed name, and the date
  • Primary physician’s signature, printed name, and the date
  • Form-preparer’s signature, printed name, and the date (if not the physician)

Step 9 – Each time the POST Form is reviewed, the reviewer will enter the date, their location, their signature, the signature of the patient (or representative), and indicate the form’s status.


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