Official  Do Not Resuscitate Order Form for New Hampshire

Official Do Not Resuscitate Order Form for New Hampshire

A Do Not Resuscitate Order (DNR) form in New Hampshire is a legal document that allows individuals to express their wishes regarding resuscitation efforts in the event of a medical emergency. This form ensures that if a person experiences cardiac arrest or respiratory failure, medical professionals will honor their decision not to receive life-saving measures. Understanding the importance of this form can empower you to make informed choices about your healthcare preferences.

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In New Hampshire, the Do Not Resuscitate (DNR) Order form serves as a critical tool for individuals who wish to make their end-of-life preferences known, particularly regarding resuscitation efforts in the event of cardiac arrest or respiratory failure. This legally recognized document allows patients to express their desire not to receive cardiopulmonary resuscitation (CPR) or other life-sustaining measures, ensuring that their wishes are respected by medical professionals. The form requires the signature of a physician, affirming that the patient has been informed about the implications of such a decision. Additionally, it is essential for individuals to discuss their choices with family members and healthcare providers to ensure that everyone understands and supports their wishes. The DNR Order form is designed to be easily accessible and is often kept in a location where it can be readily found by emergency responders. By understanding the nuances of this form, patients can take proactive steps in managing their healthcare decisions, reflecting their values and preferences during critical moments when they may no longer be able to communicate. As such, the DNR Order form represents not just a medical directive, but also a profound expression of personal autonomy and dignity in the face of serious health challenges.

Document Specifics

Fact Name Description
Purpose The New Hampshire Do Not Resuscitate Order (DNR) form allows individuals to refuse resuscitation in the event of cardiac arrest or respiratory failure.
Governing Law This form is governed by New Hampshire RSA 137-J, which outlines the legal framework for advance directives and DNR orders.
Eligibility Any adult, or a parent or legal guardian of a minor, can complete a DNR order in New Hampshire.
Signature Requirement The DNR form must be signed by the individual or their authorized representative and must be witnessed by two adults or notarized.

Key takeaways

When filling out and using the New Hampshire Do Not Resuscitate Order form, it is important to keep the following key points in mind:

  • The form must be completed by a licensed physician and signed by both the physician and the patient or their legal representative.
  • It is essential to clearly state the patient's wishes regarding resuscitation in the form.
  • The completed form should be kept in a location that is easily accessible to emergency medical personnel.
  • Patients can revoke the Do Not Resuscitate Order at any time, and this should be documented appropriately.
  • Ensure that copies of the form are provided to family members and caregivers for their awareness and understanding.
  • It is advisable to review the form periodically, especially if there are changes in the patient’s health status or treatment preferences.
  • Emergency medical services are required to honor the order as long as it is properly completed and signed.

Understanding these points can help ensure that the wishes of the patient are respected and followed in critical situations.

New Hampshire Do Not Resuscitate Order Example

New Hampshire Do Not Resuscitate Order

This Do Not Resuscitate (DNR) order is executed in accordance with New Hampshire laws regarding advance directives. It reflects the preferences of the individual named below regarding life-sustaining treatment.

Patient Information:

  • Patient Name: ______________________________
  • Date of Birth: ______________________________
  • Address: ______________________________
  • Phone Number: ______________________________

Statement of Wishes:

I, the undersigned, understand that I have the right to make decisions about my medical care. If my heart stops beating or I stop breathing, I do not want healthcare providers to perform CPR (cardiopulmonary resuscitation) or other life-saving measures.

Signature:

  • Patient Signature: ______________________________
  • Date: ______________________________

Witness Information:

This order must be witnessed by a person who is not a family member or healthcare provider.

  • Witness Name: ______________________________
  • Witness Signature: ______________________________
  • Date: ______________________________

This DNR order is effective immediately upon signing and remains in effect until revoked or modified in writing.

If you have any questions about this document, consult a healthcare provider or legal professional who can assist you further.

Important Facts about New Hampshire Do Not Resuscitate Order

What is a Do Not Resuscitate (DNR) Order in New Hampshire?

A Do Not Resuscitate Order is a legal document that allows a person to refuse resuscitation efforts in the event of a medical emergency. In New Hampshire, this order must be signed by a physician and is intended for individuals who have a terminal illness or are in a state where resuscitation would not improve their quality of life. The DNR order must be clearly documented and accessible to medical personnel to ensure that the individual’s wishes are honored.

Who can request a DNR Order?

Any adult who is capable of making their own healthcare decisions can request a DNR Order. This includes individuals with terminal illnesses or those who wish to avoid aggressive medical interventions. Additionally, a legal guardian or an authorized healthcare proxy can also request a DNR on behalf of someone who is unable to make decisions for themselves.

How do I obtain a DNR Order in New Hampshire?

To obtain a DNR Order, you must first consult with a licensed physician. During this consultation, you can discuss your medical condition and your wishes regarding resuscitation. If the physician agrees that a DNR Order is appropriate, they will complete the necessary form. It’s essential to keep a copy of the signed order in an accessible location, such as with your medical records or on your refrigerator, to ensure it can be easily found in an emergency.

Is a DNR Order valid in all healthcare settings?

Yes, a DNR Order is valid in all healthcare settings, including hospitals, nursing homes, and at home. However, it is crucial that the order is signed by a physician and is clearly documented. In some cases, specific protocols may be in place, so it is advisable to inform your healthcare providers about your DNR Order and ensure they have a copy on file.

Can a DNR Order be revoked?

Yes, a DNR Order can be revoked at any time by the individual who signed it or by their authorized representative. To revoke the order, simply inform your healthcare provider, and ensure that the DNR documentation is updated accordingly. It is important to communicate your wishes clearly to avoid any confusion in emergency situations.

What should I do if I change my mind about my DNR Order?

If you change your mind about your DNR Order, you can easily revoke it. Notify your physician and ensure that any copies of the DNR Order are destroyed or marked as revoked. You may also want to create a new order reflecting your current wishes. It’s important to communicate these changes to your healthcare providers and family members to ensure that everyone is aware of your decision.

Documents used along the form

When considering end-of-life care, several documents often accompany the New Hampshire Do Not Resuscitate (DNR) Order form. Each of these documents serves a unique purpose and helps ensure that an individual's healthcare preferences are respected. Below is a list of common forms and documents that may be used alongside a DNR order.

  • Advance Directive: This document outlines a person's wishes regarding medical treatment if they become unable to communicate. It can include preferences for life-sustaining treatments and appoint a healthcare proxy.
  • Healthcare Proxy: A healthcare proxy is a legal document that designates someone to make medical decisions on behalf of an individual if they are incapacitated.
  • Living Will: A living will is a type of advance directive that specifically details what medical treatments a person does or does not want at the end of life.
  • POLST (Physician Orders for Life-Sustaining Treatment): This form translates a patient's preferences into actionable medical orders. It is designed for patients with serious illnesses or those nearing the end of life.
  • Do Not Intubate (DNI) Order: This order specifies that a patient should not be intubated in the event of respiratory failure, complementing the DNR order.
  • Comfort Care Order: This document outlines the focus on palliative care, emphasizing comfort and quality of life rather than curative treatments.
  • Organ Donation Consent: This form allows individuals to express their wishes regarding organ donation after death, ensuring that their intentions are honored.
  • Emergency Medical Services (EMS) DNR Form: This form is specifically designed for EMS personnel to recognize a DNR order in emergency situations, ensuring that the patient’s wishes are respected.
  • Patient Information Form: This form collects essential medical information and preferences, providing healthcare providers with a comprehensive understanding of the patient's needs.
  • Durable Power of Attorney: To secure your affairs, consider the comprehensive Durable Power of Attorney resources that empower someone to make decisions on your behalf when needed.
  • Medical Power of Attorney: This document grants someone the authority to make medical decisions on behalf of another person, ensuring that their healthcare preferences are followed.

Each of these documents plays a critical role in facilitating effective communication about healthcare wishes. Together, they help ensure that individuals receive care that aligns with their values and preferences, especially during critical moments.

Consider More Do Not Resuscitate Order Forms for US States

Dos and Don'ts

When filling out the New Hampshire Do Not Resuscitate Order form, it's important to follow certain guidelines to ensure your wishes are clearly communicated. Here are seven things you should and shouldn't do:

  • Do ensure that the form is completed in full, providing all required information.
  • Do sign and date the form to validate your request.
  • Do discuss your wishes with your healthcare provider to ensure they understand your choices.
  • Do keep a copy of the signed form in a safe but accessible place.
  • Don't use unclear language or vague terms that may lead to confusion.
  • Don't forget to inform family members about your decision and where to find the form.
  • Don't assume that verbal instructions will be sufficient; written documentation is crucial.