» » Nebraska Do Not Resuscitate (DNR) Order Form

Nebraska Do Not Resuscitate (DNR) Order Form

Create a high quality document online now!

A Nebraska do not resuscitate (DNR) order form is put into a patient’s medical record when that patient does not wish to be resuscitated in the event of a cardiac arrest or if they exhibit insufficient breathing. Such orders must be filled out by the patient and signed by at least one (1) witness and a licensed physician. Furthermore, in accordance with § 20-404, an individual may draft a declaration which instructs their doctor to withhold or withdraw life-sustaining treatment in the event that they lapse into a vegetative state or incurable condition. A DNR order form is most commonly used by individuals who suffer from a severe and/or terminal illness.

Laws – § 20-404

Required to Sign – Physician, patient, and one (1) witness. For a declaration: patient and two (2) witnesses (or a notary public).

How to Write

Step 1 – Download the Nebraska DNR Order (.PDF).

Step 2 – Enter your name at the top of the page and tick the appropriate checkbox(es) to indicate “Do Not Intubate” and/or “Do Not Resuscitate (DNR).”

Step 3 – Provide your signature, the date, your address, and the signature of one (1) witness.

Step 4 – Next, enter your name, your date of birth, your doctor’s name and signature with the date. Below that, if you are filling this form out as an agency representative, provide your signature and the date.

Step 5 – If the patient’s doctor was unavailable to sign the document, check the box that indicates this is the case. Beneath the “Copy Distribution,” select the places where this DNR Order should be filed.


ABOUT SSL CERTIFICATES