Louisiana Do Not Resuscitate Order
This Do Not Resuscitate (DNR) Order is created in accordance with Louisiana state laws regarding end-of-life care. It is important to ensure that your wishes regarding resuscitation are clearly documented.
Patient Information:
- Name: ______________________________
- Date of Birth: ______________________
- Address: ____________________________
- City, State, Zip: ____________________
Healthcare Proxy Information:
- Name: ______________________________
- Relationship: ________________________
- Phone Number: _______________________
Patient Wishes:
The patient hereby states the following wishes regarding resuscitation:
- I do not wish to receive cardiopulmonary resuscitation (CPR) or other life-sustaining measures in the event of cardiac arrest.
- I understand that this order will be honored by healthcare providers in all settings.
Signature:
By signing below, I confirm that this Do Not Resuscitate Order reflects my wishes:
Patient Signature: ___________________________ Date: _______________
Witness Signature: ___________________________ Date: _______________
This document should be kept in a location that is easily accessible to healthcare providers and family members. It is recommended to discuss this order with your healthcare team to ensure that your wishes are understood and respected.