OK-P020 free printable template

FRONT PAGE OKLAHOMA DO-NOT-RESUSCITATE DNR CONSENT FORM I request limited health care as described in this document. This DNR consent form was signed in my presence. Date Signature of Witness BACK OF PAGE Address CERTIFICATION OF PHYSICIAN This form is to be used by an attending physician only to certify that an incapacitated person without a representative would not have consented to the administration of cardiopulmonary resuscitation in the event of cardiac or respiratory arrest. If my heart...stops beating or if I stop breathing no medical procedure to restore breathing or heart function will be instituted by any health care provider including but not limited to emergency medical services EMS personnel* I understand that this decision will not prevent me from receiving other health care such as the Heimlich maneuver or oxygen and other comfort care measures. 1. If I am under the care of a health care agency by making an oral written or other act of communication to a physician or...other health care provider of a health care agency 2. If I am not under the care of a health care agency by destroying my do-not-resuscitate form removing all do-not-resuscitate identification from my person and notifying my attending physician of the revocation 3. If I am incapacitated and under the care of a health care agency my representative may revoke the do-not-resuscitate consent by written notification to a physician or other health care provider of the health care agency or by oral...notification to my attending physician or revocation* I give permission for this information to be given to EMS personnel doctors nurses and other health care providers. I hereby state that I am making an informed decision and agree to a donot-resuscitate order. Signature of Person Limited to an attorney-in-fact for health care decisions acting under the Durable Power of Attorney Act a health care proxy acting under the Oklahoma Advance Directive Act or a guardian of the person appointed under...the Oklahoma Guardianship and Conservatorship Act. An attending physician of an incapacitated person without a representative must know by clear and convincing evidence that the incapacitated person when competent decided on the basis of information sufficient to constitute informed consent that such person would not have consented to the administration of cardiopulmonary resuscitation in the event of cardiac or respiratory arrest. Clear and convincing evidence for this purpose shall include...oral written or other acts of communication between the patient when competent and family members health care providers or others dose to the patient with knowledge of the patient s desires. I hereby certify based on clear and convincing evidence presented to me that I believe that Name of Incapacitated Person would not have consented to the administration of cardiopulmonary resuscitation in the event of cardiac or respiratory arrest. Therefore in the event of cardiac or respiratory arrest no...chest compressions artificial ventilation intubations defibrillation or emergency cardiac medications are to be initiated*.