This Do Not Resuscitate Order can be kept in a patient's medical records. It requests that CPR not be performed in the case of cardiac or respiratory arrest. DNR Bracelets. Do Not Resuscitate (DNR) bracelets identify a person with a valid DNR order. Before the patient receives a bracelet. The attending physician must counsel the patient, the legal guardian, or the health care agent of an incapacitated patient. The counseling session should include: Written information about DNR procedures.

This document becomes effective immediately on the date of execution for health care professionals acting in out-of-hospital settings. It remains in effect until the person is pronounced dead by authorized or authority or the document is revoked. Comfort care will be given as needed.

This form is valid only for the State of Texas. Text Version of this Form ———————– Page 1———————– Figure: 25 TAC §157.25 (h)(2) OUT-OF-HOSPITAL DO-NOT-RESUSCITATE (OOH-DNR) ORDER TEXAS DEPARTMENT OF STATE HEALTH SERVICES This document becomes effective immediately on the date of execution for health care professionals acting in out-of-hospital settings. It remains in effect until the person is pronounced dead by authorized or authority or the document is revoked. Comfort care will be given as needed. Connexions methode de francais pdf to excel. Male Person’s full name Date of birth Female A.

Declaration of the adult person: I am competent and at least 18 years of age. I direct that none of the following resuscitation measures be initiated or continued for me: cardiopulmonary resuscitation (CPR), transcutaneous cardiac pacing, defibrillation, advanced airway management, artificial ventilation. Person’s signature Date Printed name B. Declaration by guardian, agent or proxy on behalf of the adult person who is incompetent or otherwise incapable of communication: I am the: guardian; agent in a; OR proxy in a directive to physicians of the above-noted person who is incompetent or otherwise mentally or physically incapable of communication.

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Based upon the known desires of the person, or a determination of the best interest of the person, I direct that none of the following resuscitation measures be initiated or continued for the person: cardiopulmonary resuscitation (CPR), transcutaneous cardiac pacing, defibrillation, advanced airway management, artificial ventilation. Date Printed name Signature C. Declaration by a qualified relative of the adult person who is incompetent or otherwise incapable of communication: I am the above-noted person’s: spouse, adult child, parent, OR nearest living relative, and I am qualified to make this treatment decision under Health and Safety Code §166.088. To my knowledge the adult person is incompetent or otherwise mentally or physically incapable of communication and is without a guardian, agent or proxy. Based upon the known desires of the person or a determination of the best interests of the person, I direct that none of the following resuscitation measures be initiated or continued for the person: cardiopulmonary resuscitation (CPR), transcutaneous cardiac pacing, defibrillation, advanced airway management, artificial ventilation. Date Printed name Signature D.

Declaration by physician based on directive to physicians by a person now incompetent or nonwritten communication to the physician by a competent person: I am the above-noted person’s attending physician and have: seen evidence of his/her previously issued directive to physicians by the adult, now incompetent; OR observed his/her issuance before two witnesses of an OOH-DNR in a nonwritten manner. I direct that none of the following resuscitation measures be initiated or continued for the person: cardiopulmonary resuscitation (CPR), transcutaneous cardiac pacing, defibrillation, advanced airway management, artificial ventilation. Attending physician’s Printed Date Lic# signature name E. Declaration on behalf of the minor person: I am the minor’s: parent; guardian; OR managing conservator.

A physician has diagnosed the minor as suffering from a terminal or irreversible condition. I direct that none of the following resuscitation measures be initiated or continued for the person: cardiopulmonary resuscitation (CPR), transcutaneous cardiac pacing, defibrillation, advanced airway management, artificial ventilation. Date Signature Printed name TWO WITNESSES: (See qualifications on backside.) We have witnessed the above-noted competent adult person or authorized declarant making his/her signature above and, if applicable, the above-noted adult person making an OOH-DNR by nonwritten communication to the attending physician. Witness 1 signature Date Printed name Witness 2 signature Date Printed name Notary in the State of Texas and County of___________________.