Kentucky Do Not Resuscitate Order
This Do Not Resuscitate (DNR) Order is established in accordance with Kentucky state laws regarding advance directives and medical treatment preferences. It is intended to communicate the wishes of the individual regarding resuscitation efforts in the event of a medical emergency.
Patient Information:
- Name: _______________________________
- Date of Birth: _______________________
- Address: _____________________________
- City, State, Zip: _____________________
Health Care Representative (if applicable):
- Name: _______________________________
- Phone Number: ______________________
- Relationship: ________________________
Patient's Wishes:
The patient hereby states that in the event of a cardiac or respiratory arrest, no resuscitation efforts should be made. This includes, but is not limited to:
- Chest compressions
- Defibrillation
- Artificial ventilation
Signature:
By signing below, I confirm that I understand the implications of this DNR Order and that it reflects my wishes regarding resuscitation.
Signature of Patient: ___________________________
Date: ______________________________________
Witness Information:
Two witnesses are required to validate this DNR Order. Witnesses must be at least 18 years old and cannot be related to the patient or entitled to any portion of the patient’s estate.
- Witness 1 Name: ___________________________
- Witness 1 Signature: ______________________
- Date: ___________________________________
- Witness 2 Name: ___________________________
- Witness 2 Signature: ______________________
- Date: ___________________________________
This Do Not Resuscitate Order is effective immediately upon signing and remains in effect until revoked by the patient or their authorized representative.