Attorney-Verified Do Not Resuscitate Order Template for New Hampshire

New Hampshire Do Not Resuscitate Order Template

This document serves as a Do Not Resuscitate (DNR) Order in accordance with the New Hampshire Revised Statutes Annotated (RSA) related to the use of life-sustaining treatment. It is designed to inform healthcare providers about the patient's wishes regarding resuscitation attempts in the event of a respiratory or cardiac arrest. Please complete all sections of this template to ensure that your healthcare preferences are understood and respected.

Patient Information:

• Full Name: ___________________________
• Date of Birth: ___________________________
• Address: ___________________________
• Phone Number: ___________________________

Primary Care Physician Information:

• Physician's Name: ___________________________
• Contact Number: ___________________________
• Hospital or Clinic Name: ___________________________

By completing this order, I, ____________________ (patient's name), understand that I am directing medical personnel not to perform cardiopulmonary resuscitation (CPR) in the event my heart and/or breathing stops. This order does not affect the provision of other medical care, including treatment for pain, difficulty breathing, or other discomforts.

Witness Information:

• Witness Name: ___________________________
• Relationship to Patient: ___________________________
• Witness Signature: ___________________________ Date: ___________________________

Acknowledgment by Physician:
I, ____________________ (physician's name), certify that I have discussed the implications of this Do Not Resuscitate (DNR) Order with the patient named above and that the patient understands the nature of the DNR and its consequences.

• Physician's Signature: ___________________________ Date: ___________________________

This DNR Order is valid immediately upon completion and remains in effect until it is revoked. To revoke this order, the patient or their legal representative must notify the attending physician or healthcare provider orally or in writing.

Important: This DNR Order should be kept in a location where it is easily accessible to EMS personnel and healthcare providers. Consider providing copies to family members, close friends, and your primary care physician.

Note: This template is provided for informational purposes and should be reviewed by a healthcare provider and legal advisor before being finalized. Laws and regulations regarding DNR orders vary by state and may change over time.