DO NOT RESUSCITATE ORDER

1.  PATIENTS NAME: ______________________________________

2.  DO NOT RESUSCITATE

3.  ATTENDING PHYSICIAN'S NAME: _________________________

4.  ATTENDING PHYSICIAN'S SIGNATURE: ____________________

5.  EFFECTIVE DATE: _____________________________________

6.  CONSENT SIGNATURE: _________________________________

      PRINT NAME: _________________________________________

SIGNATURE OF:

__ PATIENT  ___ LEGAL GUARDIAN  ___  SURROGATE DECISION MAKER

__ DURABLE POWER OF ATTORNEY FOR HEALTHCARE

This order may be physically destroyed or verbally revoked at any time by either the Physician or by the person who gave consent.

Note:  Under Illinois state law (210 ILCS 50 and 77 Ill. Adm. Code 515), all ambulance crews are required to make a resuscitation attempt and transport to the closest emergency department in the event of a cardiopulmonary arrest in a patient under their care, unless a "Do Not Resuscitate" (DNR) order containing the six (6) elements listed above has been completed and a copy given to the ambulance crew at the time of the transport.  If a "Do Not Resuscitate" (DNR) order has been supplied which does not contain all of the listed elements, the ambulance crew will not be able to honor in the event of an arrest.