Printable Do Not Resuscitate Order Template for Illinois State
The Illinois Do Not Resuscitate Order (DNR) form serves as a crucial tool for individuals wishing to express their preferences regarding medical treatment in the event of a life-threatening situation. This legally recognized document allows patients, or their authorized representatives, to communicate a desire to forego resuscitative efforts, such as cardiopulmonary resuscitation (CPR), in circumstances where their heart stops or they stop breathing. The form is designed to be straightforward, ensuring that patients can easily articulate their wishes regarding end-of-life care. It must be completed and signed by a physician, emphasizing the importance of medical guidance in these deeply personal decisions. Additionally, the DNR form must be readily available to healthcare providers, as its presence is vital for honoring the patient's wishes during emergencies. Understanding the implications of this form is essential for both patients and their families, as it addresses not only medical considerations but also the emotional and ethical dimensions of end-of-life care. By navigating this complex landscape, individuals can ensure that their values and preferences are respected, even in the most critical moments of their lives.
Example - Illinois Do Not Resuscitate Order Form
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.
PDF Form Properties
| Fact Name | Details |
|---|---|
| Definition | The Illinois Do Not Resuscitate (DNR) Order form allows individuals to refuse resuscitation efforts in the event of a medical emergency. |
| Governing Law | The form is governed by the Illinois DNR Law, specifically the Illinois Compiled Statutes, Chapter 410, Act 50. |
| Eligibility | Any adult can complete a DNR Order, including those with terminal illnesses or advanced directives. |
| Signature Requirement | The form must be signed by the individual or their authorized representative, along with a witness signature. |
| Healthcare Provider Notification | Healthcare providers must be notified of the DNR Order to ensure it is honored during emergencies. |
| Form Availability | The DNR Order form is available online through the Illinois Department of Public Health website. |
| Revocation | Individuals can revoke a DNR Order at any time, and it must be documented appropriately. |
| Emergency Medical Services | Emergency medical services (EMS) personnel are required to honor a valid DNR Order in the field. |
| Additional Considerations | It is advisable to discuss the DNR Order with family members and healthcare providers to ensure everyone is informed. |
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