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NOTICE OF PATIENT OR AUTHORIZED AGENT'S DIRECTIVE TO WITHHOLD CARDIOPULMINARY RESUSCITATION (CPR)
State of __________________
Patient's Name: ______________________________________________
Name of: Authorized agent/proxy:______________________________
Date of Birth ___/___/___ Gender: ___Male ___Female
Eye Color: __________ Hair Color: ________
Race/Ethnicity:____________________________________________
Name of hospice program (if applicable) ___________________
Attending Physician: ______________________________________
Physician's Address: ______________________________________
Physician's Phone:____________ Physician's License:________
Directive made on this date: ________ pursuant to state law
Check ONLY one of the following (as appropriate):
______ PATIENT: I am over the age of 18 years, of sound mind and acting voluntarily. It is my desire to initiate this
directive on my behalf, and I have been advised that the expected result of executing this directive is my death, in the event
that my heart or breathing stops or malfunctions.
______ AUTHORIZED AGENT/PROXY: I am over the age of 18 years of age, of sound mind, and I am legally authorized to act
on behalf of the patient named above in the issuance of this directive. I have been advised that the expected result of executing
this directive is the death of the patient, in the event the patient's heart or breathing stops or malfunctions.
I hereby direct emergency medical services personnel, health crae providers, and any other person to withhold cardiopulmonary
resuscitation in the event that my/the patient's heart or breathing stops or malfunctions. I understand that this directive
does not apply to other medical interventions for comfort care. If I/the patient am/is admitted to a health care facility,
this directive shall be implemented as a physician's order, pending further physician's orders.
USE ORIGINAL SIGNATURES ON EACH PAGE OF THS FORM MAKES EACH PAGE AN ORIGINAL DOCUMENT
__________________________________________________________
Signature of ____ Patient or ____ Authorized agent/proxy
__________________________________________________________
Signature of attending physician
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When this form is filled out, put in a sheet protector and hang in a visible place where emergency personnel will see it upon
entering. This protects the frail elderly from having painful procedures done (such as paddles) when their life is clearly
nearing the end. It allows them to have a peaceful, natural death and not bear the indignity of more pain and further heartbreak
for you having to subsequently take them off of pointless "life" support.
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