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Pennsylvania Do Not Resuscitate (DNR) Order Form – Sample Only

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The Pennsylvania do not resuscitate (DNR) order form provides an individual with the ability to avoid life-saving treatments in the event that they experience cardiac or respiratory arrest. The DNR is valid once signed by the patient (or authorized representative) and the patient’s physician. Subsequently, if EMS providers attend to the patient and view the DNR, or if they see the patient’s DNR necklace or bracelet, CPR will not be attempted and the patient will die naturally. A doctor or other medical professional will be able to provide the official document, though a sample DNR form is available below.

Laws § 5481 – § 5488

Required to Sign – Patient (or surrogate if the patient is unable to sign) and physician.

Orders for Life-Sustaining Treatment – A separate DNR form that allows the patient to specify in greater detail the actions which are to be taken by EMS providers when the patient has no pulse or is not breathing.

How to Write

Step 1 – The sample DNR form can be downloaded in Adobe PDF.

Step 2 – Enter the patient’s name in the first available field.

Step 3 – In section (2)A, enter the physician’s name next to the word “Printed.” The physician should not sign the form or enter the date in this section until the patient (or surrogate) has signed.

Step 4 – Also in section (2)A, enter the physician’s emergency telephone number before selecting “Yes” or “No” to indicate whether a DNR bracelet or necklace is requested.

Step 5 – Section (2)B should only be completed if the patient is a woman who is pregnant at the time the DNR order is executed. The physician will need to provide their signature, print their name, and enter the date that the document was signed.

Step 6 – Section (3)A should only be completed if the patient is capable of furnishing their signature. If the patient agrees to the conditions of the DNR order, they must supply their signature on the right. They must then specify when they signed by entering the date in the space to the left.

Step 7 – Section (3)B should only be completed if the patient is unable to sign the DNR and there is a surrogate who is legally authorized to execute the order on their behalf. In the first space, the surrogate must specify their relationship to the patient. In the remaining areas, the surrogate must provide their signature and enter the date that the document was signed.

Step 8 – Go back to section (2)A and, in the remaining two (2) spaces, the physician must provide their signature and enter the date of signing. The document will be effective once signed by the physician and it will remain in effect until the patient dies or the order is revoked.


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