Kansas Do Not Resuscitate Order
This Do Not Resuscitate (DNR) Order is executed in accordance with the Kansas Statutes Annotated, specifically K.S.A. 65-4942 et seq. This document indicates the desire of the individual named below to forgo resuscitative measures in the event of cardiac or respiratory arrest.
Patient Information:
- Name: ______________________________
- Date of Birth: ______________________
- Address: ____________________________
- City, State, Zip: ____________________
Health Care Provider Information:
- Name: ______________________________
- Phone Number: ______________________
- Address: ____________________________
Patient's Wishes:
The patient, named above, does not wish to receive resuscitation efforts in the event of cardiac or respiratory arrest. This includes, but is not limited to:
- Cardiopulmonary resuscitation (CPR)
- Advanced airway management
- Defibrillation
Signature of Patient or Legal Representative:
By signing below, I confirm that I have discussed this DNR Order with the patient (or their legal representative) and that it reflects their wishes.
Signature: ___________________________
Date: _______________________________
Witness Information:
- Name: ______________________________
- Signature: __________________________
- Date: _______________________________
This DNR Order should be placed in the patient's medical records and a copy should be provided to all relevant healthcare providers.