Attorney-Approved Georgia Do Not Resuscitate Order Template
Contents
In Georgia, the Do Not Resuscitate (DNR) Order form serves as a critical document for individuals wishing to express their preferences regarding medical interventions in the event of a cardiac or respiratory arrest. This legally binding order allows patients to communicate their desire to forgo resuscitation efforts, such as chest compressions or intubation, should they experience a life-threatening emergency. The form is typically completed by a patient or their authorized representative, and it must be signed by a physician to ensure its validity. Importantly, the DNR Order must be readily accessible to medical personnel, as it guides healthcare providers in respecting the patient's wishes during critical moments. In addition to its medical implications, the form also emphasizes the importance of informed decision-making, allowing individuals to discuss their values and preferences with family members and healthcare providers. Understanding the nuances of the DNR Order is essential for anyone considering this option, as it encompasses not only legal and medical aspects but also deeply personal choices about end-of-life care.
Georgia Do Not Resuscitate Order Example
Georgia Do Not Resuscitate Order (DNR)
This document serves as a Do Not Resuscitate (DNR) order in accordance with Georgia laws, specifically the Georgia Advanced Directive for Health Care Act. It is designed to inform medical personnel of the patient's wish not to have cardiopulmonary resuscitation (CPR) in the event that their breathing stops or if their heart stops beating.
Patient Information
- Full Name: ___________________________
- Date of Birth: ___________________________
- Address: ___________________________
- City, State, Zip Code: ___________________________
- Primary Contact Name: ___________________________
- Relationship to Patient: ___________________________
- Contact Number: ___________________________
Do Not Resuscitate (DNR) Order
As the patient named above, I direct any and all healthcare providers, in accordance with Georgia state law, to withhold or withdraw cardiopulmonary resuscitation (CPR), including mechanical respiration, defibrillation, administration of medications for cardiac resuscitation, and other such procedures that artificially prolong life in the event my heart and/or breathing cease. This order does not affect the provision of other emergency treatments, including pain relief, nutrition, and hydration, as I may desire.
I understand that this order will remain in effect until I revoke it. I am aware that I may revoke this order at any time, in accordance with Georgia state law, either verbally or by destroying this document.
Signature
Patient's Signature: ___________________________ Date: ___________________________
If the patient is unable to sign, a designated surrogate may sign on the patient's behalf:
- Surrogate's Name: ___________________________
- Relationship to Patient: ___________________________
- Signature: ___________________________ Date: ___________________________
Physician's Statement
This section to be completed by a licensed Georgia physician:
I, ___________________________ (physician's name), hereby affirm that the patient named above has discussed this Do Not Resuscitate order with me. I have explained the nature and consequence of this order, including its potential to limit lifesaving measures in the event of cardiac or respiratory arrest.
Physician's Signature: ___________________________ Date: ___________________________
Medical License Number: ___________________________
Document Information
| Fact Name | Details |
|---|---|
| Definition | A Do Not Resuscitate (DNR) Order is a legal document that instructs medical personnel not to perform cardiopulmonary resuscitation (CPR) if a patient's heart stops or they stop breathing. |
| Governing Law | The DNR Order in Georgia is governed by O.C.G.A. § 31-39-1, which outlines the regulations and procedures for such orders. |
| Eligibility | Any adult may complete a DNR Order, but it must be signed by a physician and the patient or their legal representative. |
| Form Requirements | The DNR Order must be in writing, signed by a physician, and should include the patient's name and date of birth. |
| Revocation | A DNR Order can be revoked at any time by the patient or their legal representative, either verbally or in writing. |
| Emergency Services | Emergency medical services (EMS) personnel are required to honor the DNR Order if it is presented at the time of an emergency. |
| Storage | Patients should keep the DNR Order in an easily accessible location, such as on the refrigerator or with their medical records. |
| Additional Documentation | It is advisable to inform family members and caregivers about the DNR Order to ensure everyone is aware of the patient's wishes. |
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