Kentucky Do Not Resuscitate Order
This Do Not Resuscitate (DNR) Order is created in accordance with Kentucky state laws regarding advance directives. It is intended to communicate the wishes of the individual regarding resuscitation efforts in the event of a medical emergency.
Patient Information:
- Name: ___________________________
- Date of Birth: ____________________
- Address: _________________________
- Phone Number: ____________________
Health Care Decision Maker (if applicable):
- Name: ___________________________
- Relationship: ______________________
- Phone Number: ____________________
Statement of Intent:
I, the undersigned, hereby declare that I do not wish to receive cardiopulmonary resuscitation (CPR) or other resuscitative measures in the event of cardiac or respiratory arrest.
Signature:
___________________________
Date:
___________________________
Witness Information:
- Name: ___________________________
- Signature: ________________________
- Date: ____________________________
This DNR Order should be placed prominently in the patient's medical records and should be communicated to all relevant healthcare providers.
For more information about advance directives and DNR orders in Kentucky, please consult with a healthcare professional or legal advisor.