Illinois Do Not Resuscitate (DNR) Order Template
This document serves as a Do Not Resuscitate (DNR) Order adhering to the guidelines and laws specific to the State of Illinois, including but not limited to the Illinois Compiled Statutes. This DNR Order is intended to inform medical professionals of the patient's wish not to receive cardiopulmonary resuscitation (CPR) in the event that the patient's breathing stops or the heart stops beating.
Patient Information
Please fill in the following information:
- Full Name: _______________
- Date of Birth: _______________
- Address: _______________
- City, State, Zip Code: _______________
- Phone Number: _______________
DNR Order Declaration
I, _________________ (the "Patient"), being of sound mind and legal age, hereby direct any and all medical professionals, in accordance with Illinois state laws, specifically the Illinois Compiled Statutes, to withhold or withdraw cardiopulmonary resuscitation (CPR) in the event my breathing ceases or my heart stops beating. This decision is made knowingly and voluntarily and reflects my wish to decline life-sustaining treatment under such circumstances.
Physician's Statement
This section must be completed by a licensed physician:
I, Dr. _________________, a licensed physician in the State of Illinois, ID# _______________ hereby certify that I have discussed the nature and consequences of a Do Not Resuscitate (DNR) order with the patient named above. I have offered the patient the opportunity to ask questions and seek alternative advice, and I am satisfied that the patient's decision is informed and voluntary.
Signature
Patient's Signature: _______________ Date: _______________
Physician's Signature: _______________ Date: _______________ Phone Number: _______________
Witness Declaration
This DNR order must be witnessed by at least one individual who is not related to the patient by blood, marriage, or adoption and is not entitled to any part of the patient’s estate upon death. The witness must be of sound mind and at least 18 years old.
Witness's Name: _______________
Witness's Signature: _______________ Date: _______________
Note: This form does not substitute for legal advice. Consider consulting a healthcare advocate, attorney, or medical professional to ensure that this document complies with current Illinois law and accurately reflects your wishes.