Louisiana Do Not Resuscitate Order Template
This Do Not Resuscitate (DNR) Order is created in accordance with Louisiana state laws regarding advance directives and medical decisions. It is designed to express the wishes of the individual regarding resuscitation efforts in the event of a medical emergency.
Patient Information:
- Full Name: ____________________________
- Date of Birth: ________________________
- Address: ______________________________
- City, State, Zip Code: _______________
Healthcare Proxy Information:
- Full Name: ____________________________
- Relationship to Patient: _______________
- Phone Number: _______________________
Order Statement:
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.
Signature: _______________________________
Date: ___________________________________
Witness Information:
- Witness Name: ________________________
- Witness Signature: _____________________
- Date: _________________________________
This document must be signed by the patient or their legally authorized representative and witnessed by at least one individual who is not related to the patient or entitled to any portion of the patient’s estate.
It is advisable to keep copies of this DNR Order in accessible locations, such as with your healthcare provider and family members. Ensure that all parties involved in your care are aware of your wishes.