Nebraska Do Not Resuscitate Order
This Do Not Resuscitate (DNR) Order is established in accordance with Nebraska state laws regarding advance directives and medical treatment preferences.
Patient Information:
- Name: ____________________________
- Date of Birth: _____________________
- Address: __________________________
- City, State, Zip: _________________
Healthcare Provider Information:
- Provider Name: _____________________
- Provider Phone Number: ______________
Statement of Wishes:
I, the undersigned, declare that I do not wish to receive cardiopulmonary resuscitation (CPR) or other life-sustaining treatment in the event of cardiac or respiratory arrest.
Patient Signature: ____________________________
Date: ____________________________
Witness Information:
- Witness Name: ______________________
- Witness Signature: ___________________
- Date: _______________________________
Important Notes:
- This order must be signed by the patient or their legal representative.
- It is recommended to keep a copy of this DNR Order in a visible location.
- Inform family members and healthcare providers about this decision.
This document reflects my wishes and should be honored by all medical personnel.