DO NOT RESUSCITATE ORDER FOR _______________________ ATTENTION!

DO NOT RESUSCITATE ORDER FOR _______________________ ATTENTION! DO NOT MAKE ANY ATTEMPT TO RESUSCITATE THIS PATIENT! This document represents the official request, legal in the State of _______________________, to order all medical personnel to cease any attempt to resuscitate the Patient and allow a natural death. Section I, II, III, or IV must be completed along with Section V. I. Patient Request I, _______________________, the undersigned Patient, direct that resuscitative measures be withheld from me in the event of cardiopulmonary cessation. I have discussed this decision with my physician, and I understand the consequences of this decision. Signature of Patient _______________________ Date ____________ Section II. Advance Directive/Living Will I, _______________________, an Authorized Representative of _______________________ [Hospital/Medical Facility], hereby attest the Patient is no longer competent or able to understand, appreciate, and direct their medical treatment with no hope of regaining that ability. Therefore, I agree to follow a duly executed Advance Directive/Living Will with health care instructions specifying that no life-sustaining treatment be provided was previously authorized by the Patient and has been made part of their medical record. Signature of Representative _______________________ Date ____________ Section III. Medical Power of Attorney – Agent/Attorney-in-Fact Consent I, _______________________, the Agent/Attorney-in-Fact for the Patient as designated by a duly executed Medical Power of Attorney or equivalent document reserve the right to make decisions regarding the providing, withholding, or withdrawal of life-sustaining treatment for the Patient. Therefore, I hereby direct that resuscitative measures be withheld from the Patient in the event of cardiopulmonary cessation. A copy of the Agent/Attorney-in-Fact designation (e.g. living will, power of attorney, advance directive, etc.) has been attached and made part of the Patient’s medical record. Signature of Agent/Attorney-in-Fact _______________________

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