New Jersey Do Not Resuscitate (DNR) Order
This document serves as a Do Not Resuscitate (DNR) Order following the guidelines set forth by the state of New Jersey. It is designed to inform medical personnel that the individual named herein does not wish to have cardiopulmonary resuscitation (CPR) in the event that their breathing stops or their heart ceases to beat.
Patient Information
Patient Name: ___________________________________________
Address: __________________________________________________
Date of Birth: _______________ Phone: _____________________
Social Security Number: ___________________________________
Medical Practitioner Information
Physician's Name: ________________________________________
License Number: _________________________________________
Address: __________________________________________________
Phone: ___________________________________________________
Do Not Resuscitate Order Declaration
This DNR Order is to be applied with immediate effect and will remain in force permanently until revoked. The signing of this document indicates the informed and voluntary consent of the patient, or their legally authorized representative, to the DNR order as described herein, per the guidelines of the New Jersey Department of Health.
Witness Declaration
In confirmation that this DNR Order reflects the wishes of the patient without any undue pressure, and that the patient, or their legally authorized representative, had the mental capacity to make this decision, a witness is required to sign this document.
Witness Name: ___________________________________________
Relationship to Patient: _________________________________
Date: ___________________________________________________
Signature
Patient or Legally Authorized Representative:
___________________________________________
Date: ___________________________________________________
Physician's Signature:
___________________________________________
Date: ___________________________________________________
Completion of this form adheres to the provisions of New Jersey law concerning DNR orders. It is recommended to keep this document easily accessible and to inform family members, caregivers, and healthcare providers of its existence and location.
Instructions for Revocation
To revoke this DNR Order, the patient or their legally authorized representative must inform the attending physician or healthcare provider verbally or through written communication. It is advisable to also destroy physical copies of the DNR Order to prevent unintentional use.
