Homepage Attorney-Verified Do Not Resuscitate Order Template for New Hampshire
Content Overview

In New Hampshire, the Do Not Resuscitate (DNR) Order form serves as an important tool for individuals wishing to express their preferences regarding medical treatment in emergency situations. This legally binding document allows patients to communicate their desire not to receive cardiopulmonary resuscitation (CPR) or other life-sustaining measures in the event of a cardiac or respiratory arrest. The form must be completed and signed by a qualified healthcare provider, ensuring that it reflects the patient's wishes accurately and complies with state regulations. Importantly, the DNR Order is designed to be easily recognizable by emergency medical personnel, who are trained to respect the wishes outlined in the document. Additionally, individuals can discuss their choices with family members and healthcare professionals to ensure that everyone understands the implications of the order. By understanding the DNR Order form, individuals can take proactive steps to ensure that their healthcare preferences are honored, even when they are unable to communicate them directly.

New Hampshire Do Not Resuscitate Order Sample

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.

PDF Specs

Fact Name Description
Definition A Do Not Resuscitate (DNR) Order in New Hampshire is a legal document that allows a person to refuse resuscitation in the event of cardiac or respiratory arrest.
Governing Law The DNR Order in New Hampshire is governed by RSA 137-J, which outlines the requirements and procedures for creating a valid DNR.
Eligibility Any adult can complete a DNR Order, but it must be signed by the individual and a physician to be valid.
Healthcare Provider Obligations Healthcare providers must respect a valid DNR Order and are required to follow the wishes expressed in the document.
Revocation A DNR Order can be revoked at any time by the individual, either verbally or in writing, allowing for flexibility in medical decisions.
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