Nebraska Do Not Resuscitate Order
This Do Not Resuscitate (DNR) Order is created in accordance with Nebraska state laws regarding advance directives and end-of-life care.
Patient Information:
- Name: ______________________________
- Date of Birth: ______________________
- Address: ____________________________
- City: ________________________________
- State: Nebraska
- Zip Code: __________________________
Health Care Provider Information:
- Provider Name: ______________________
- Provider Phone: _____________________
Patient's Wishes:
The patient, named above, does not wish to receive cardiopulmonary resuscitation (CPR) or other life-sustaining measures in the event of cardiac or respiratory arrest.
Signature:
By signing below, the patient or the patient's authorized representative confirms this Do Not Resuscitate Order:
Patient/Representative Signature: ________________________
Date: ______________________
Witness Information:
- Witness Name: ______________________
- Witness Signature: ___________________
- Date: _______________________________
This document should be kept in a safe place and shared with family members and health care providers to ensure that the patient's wishes are honored.