Delaware Do Not Resuscitate Order Template
This Do Not Resuscitate (DNR) Order is created in accordance with Delaware law, specifically 16 Del. C. § 2502. This document expresses the wishes of the individual regarding resuscitation efforts in the event of a medical emergency.
Patient Information:
- Name: _______________________________
- Date of Birth: _______________________
- Address: _____________________________
- City: ________________________________
- State: Delaware
- Zip Code: ___________________________
Health Care Provider Information:
- Name: _______________________________
- License Number: ______________________
- Contact Number: ______________________
Order Details:
This DNR Order indicates that the patient does not wish to receive cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest.
Signature:
By signing below, I confirm that I understand the implications of this order and that it reflects my wishes:
- Patient's Signature: ____________________
- Date: _________________________________
Witness Information:
- Name: _______________________________
- Signature: ___________________________
- Date: _________________________________
Additional Notes:
Please ensure that copies of this DNR Order are provided to all relevant health care providers and kept in the patient’s medical records.