This North Dakota Do Not Resuscitate Order Template is designed to assist residents of North Dakota in communicating their wishes regarding resuscitative efforts in the event of a cardiac or respiratory arrest. This document is guided by the North Dakota Century Code section relevant to Do Not Resuscitate (DNR) orders. Please provide accurate and complete information where blanks are present to ensure the document meets your needs.
Patient Information:
- Full Name: ___________________________________________________
- Date of Birth: _________________________________________________
- Address: ______________________________________________________
- City: ________________________ State: ND Zip Code: ______________
- Phone Number: ________________________________________________
Do Not Resuscitate Directive:
I, ___________________________________ (full name), being of sound mind and legal age, hereby direct any and all healthcare providers, under the laws of the State of North Dakota, to withhold or withdraw cardiopulmonary resuscitation (CPR) or other forms of resuscitative efforts in the event my breathing and/or heart stops. This order does not affect the provision of other forms of medical care designed to provide comfort or alleviate pain.
Signature Section:
Patient (or Legally Authorized Representative) Signature: ____________________________________ Date: _______________
Print Name of Patient (or Representative): ___________________________________________________
Relationship to Patient (if signed by Representative): _________________________________________
Witness Signature: ____________________________________________ Date: _______________
Print Name of Witness: ___________________________________________________________
Physician's Section:
I, ___________________________________ (physician's name), confirm that the patient (or their legally authorized representative) has discussed with me, understands, and has voluntarily requested the issuance of a Do Not Resuscitate Order under the guidelines of North Dakota law.
Physician Signature: __________________________________________ Date: _______________
Print Name of Physician: _________________________________________________________
Medical License Number: _________________________________________________________
Contact Information: _____________________________________________________________
Please review all information for accuracy before signing. This document should be kept in a place where it can be easily accessed by family members, caregivers, and healthcare professionals. A copy should also be provided to your primary healthcare provider.
