A Tennessee Do Not Resuscitate Order (DNR) form is a legal document that allows individuals to express their wishes regarding resuscitation efforts in the event of a medical emergency. This form provides clarity for healthcare providers and loved ones about a person's preferences for life-sustaining treatments. Understanding how to complete and implement this form is essential for ensuring that one's healthcare choices are respected.
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The Tennessee Do Not Resuscitate (DNR) Order form is an essential document for individuals who wish to communicate their preferences regarding medical interventions in the event of a life-threatening situation. This form allows patients to express their desire not to receive cardiopulmonary resuscitation (CPR) if their heart stops beating or if they stop breathing. It is particularly significant for those with terminal illnesses or severe health conditions, as it ensures that their wishes are respected during critical moments. The DNR form must be completed and signed by a physician, confirming that the patient has been informed of the implications and consequences of their decision. Additionally, the form should be easily accessible to emergency medical personnel, ensuring that it is honored when necessary. Understanding the nuances of the DNR Order is crucial for both patients and their families, as it facilitates informed decision-making and fosters conversations about end-of-life care. In Tennessee, this form plays a vital role in the broader context of advance care planning, empowering individuals to take control of their medical treatment preferences.
Tennessee Do Not Resuscitate (DNR) Order
This document is prepared in accordance with the specific provisions found within the Tennessee Department of Health guidelines and the Tennessee Health Care Decisions Act. It serves as a directive for healthcare providers regarding the administration of cardiopulmonary resuscitation (CPR) to the undersigned individual in the event of cardiac or respiratory arrest. A DNR order does not affect the provision of other medical interventions designed to provide comfort care or to alleviate pain.
Patient Information
Full Legal Name: _________________________ Date of Birth: _________________________ Address: _________________________ Telephone Number: _________________________
Primary Physician Information
Physician's Full Legal Name: _________________________ License Number: _________________________ Address: _________________________ Telephone Number: _________________________
DNR Order
I, _________________________, being of sound mind, direct that in the event my heart stops beating or if I stop breathing, no medical procedure to restart breathing or heart functioning shall be initiated by any healthcare provider, including emergency medical services personnel. I understand the full import of this order and assume all risks for my health that may follow from this decision.
Signature
Patient's Signature: _________________________ Date: _________________________
OR
If the patient is physically or otherwise unable to sign, a representative may sign on behalf of the patient as indicated below:
Representative's Full Legal Name: _________________________ Relationship to Patient: _________________________ Signature: _________________________ Date: _________________________
Physician's Verification
This section to be completed by the primary physician or attending physician:
I, _________________________, verify that the individual or their authorized representative, whose signature appears above, has discussed with me the implications of this Tennessee Do Not Resuscitate Order. I have informed them of the nature of a DNR order, possible outcomes, and alternatives. This DNR order reflects the patient's current medical condition and wishes.
Physician's Signature: _________________________ Date: _________________________ Physician's Stamp/Seal (If applicable): _________________________
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