Massachusetts Do Not Resuscitate Order Document

Massachusetts Do Not Resuscitate Order (DNR)

This Do Not Resuscitate Order complies with the Massachusetts laws and regulations governing such directives. It is a legal document indicating that the person named below does not wish to receive cardiopulmonary resuscitation (CPR) in the event their heart stops or they stop breathing.

Personal Information

Name: ___________________________________

Address: ___________________________________

Date of Birth: ___________________________________

Phone Number: ___________________________________

Medical Information

Primary Physician: ___________________________________

Physician Phone Number: ___________________________________

Do Not Resuscitate (DNR) Directive

I, ____________________ (initial here), being of sound mind and understanding the implications of this directive, hereby refuse any form of cardiopulmonary resuscitation (CPR), including but not limited to manual chest compressions, artificial ventilation, or advanced airway management. This directive is to be followed by any health care provider or emergency medical services personnel who are present at the time of my cardiac or respiratory arrest.

This order does not affect the provision of other emergency care, including oxygen, pain relief, or comfort care.

Legal Witness

In accordance with Massachusetts state regulations, this document must be signed in the presence of a witness. The witness confirms that the individual signing this document appears to do so voluntarily and without duress.

Signatures

Individual's Signature: _______________________________ Date: ________________

Witness Signature: _______________________________ Date: ________________

Physician Signature: _______________________________ Date: ________________

Contact Information

For additional information or assistance with completing this document, please contact:

• Massachusetts Department of Public Health
• Primary Physician's Office
• Legal Advisor

This document should be reviewed regularly and can be revoked or amended by the individual at any time. A copy of this directive should be provided to your primary physician, included in your medical records, and kept in a place where it is easily accessible to emergency responders.