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Homepage ⇝ Blank Do Not Resuscitate Order Form for the State of Indiana
Overview

Indiana Do Not Resuscitate Order Sample

Indiana Do Not Resuscitate Order

This Do Not Resuscitate (DNR) Order complies with Indiana state law. It allows individuals to express their wishes regarding medical treatment in the event of a life-threatening situation.

In accordance with Indiana Code § 16-36-4, the following information must be provided:

  • Patient's Name: ________________________
  • Date of Birth: ________________________
  • Address: ________________________
  • City, State, Zip Code: ________________________

This DNR Order applies to the following situation:

  • In the event of cardiac arrest or respiratory failure.
  • No resuscitative measures will be taken.

Patient's Wishes: I, ________________________ (patient's name), do not wish to receive cardiopulmonary resuscitation (CPR), mechanical ventilation, or any other life-sustaining treatment in the event of my cardiac arrest.

Signature: ________________________

Date: ________________________

If designated, please provide the following information for the patient's representative:

  • Name of Representative: ________________________
  • Relationship to Patient: ________________________
  • Contact Number: ________________________

This DNR Order should be kept in a visible location and shared with all healthcare providers involved in the patient's care.

Witness Statement:

  1. Name of Witness: ________________________
  2. Signature: ________________________
  3. Date: ________________________

By signing this document, I affirm that the information provided is accurate and that the patient understands their rights regarding this Order.

PDF Properties

Fact Name Description
Purpose The Indiana Do Not Resuscitate (DNR) Order form allows individuals to express their wish not to receive cardiopulmonary resuscitation (CPR) in the event of cardiac arrest.
Eligibility Any adult who is capable of making healthcare decisions can complete a DNR Order. This includes individuals with terminal illnesses or those who wish to avoid aggressive medical interventions.
Governing Law The DNR Order in Indiana is governed by Indiana Code 16-36-6, which outlines the requirements and procedures for creating a valid DNR Order.
Signature Requirements The form must be signed by the individual or their legally authorized representative. Additionally, it requires the signature of a physician to be valid.

Essential Points on This Form

What is the Indiana Do Not Resuscitate Order form?

The Indiana Do Not Resuscitate Order (DNR) form is a legal document that allows an individual to express their wishes regarding resuscitation efforts in the event of a medical emergency. This form is particularly important for individuals with terminal illnesses or severe health conditions who wish to avoid aggressive life-saving measures, such as cardiopulmonary resuscitation (CPR), when their heart or breathing stops. By completing this form, patients can ensure that their preferences are respected by healthcare providers and family members during critical moments.

Who can complete the Indiana DNR Order form?

The form can be completed by individuals who are at least 18 years old and capable of making their own healthcare decisions. In cases where the individual is unable to complete the form, a legally authorized representative, such as a healthcare proxy or a durable power of attorney for healthcare, may fill it out on their behalf. It is essential that the individual or their representative fully understands the implications of the DNR order and discusses their wishes with family members and healthcare providers before signing the document.

How do I obtain and complete the Indiana DNR Order form?

The Indiana DNR Order form can typically be obtained from healthcare providers, hospitals, or online through state health department websites. To complete the form, follow these steps:

  1. Download or request a physical copy of the DNR form.
  2. Read the instructions carefully to understand the options available.
  3. Fill out the required information, including personal details and preferences regarding resuscitation.
  4. Sign the form in the presence of a witness, who must also sign it.
  5. Provide copies to your healthcare provider and family members.

It is advisable to keep the original document in a safe but accessible location, ensuring that it can be easily found in an emergency.

What should I do if I change my mind about my DNR Order?

If you decide to change your mind about your DNR Order, it is important to revoke the existing document formally. You can do this by:

  • Destroying the original DNR form.
  • Notifying your healthcare provider and family members about your decision.
  • Completing a new DNR Order form if you wish to establish different preferences.

Communicating your wishes clearly to all relevant parties is crucial to ensure that your current preferences are honored in any future medical situations.

Misconceptions

Understanding the Indiana Do Not Resuscitate (DNR) Order form is crucial for making informed decisions about medical care. Unfortunately, several misconceptions can cloud this important topic. Below are some common misunderstandings, along with clarifications to help you navigate this sensitive area.

  • A DNR order means no medical care at all. This is not true. A DNR order specifically addresses the use of CPR and other resuscitation efforts. Patients with a DNR can still receive other types of medical care, including medications and comfort measures.
  • Only terminally ill patients can have a DNR order. This misconception overlooks the fact that anyone, regardless of their health status, can choose to have a DNR order. It is a personal choice based on individual values and preferences regarding end-of-life care.
  • A DNR order is permanent and cannot be changed. In reality, a DNR order can be revoked or modified at any time. If circumstances change or if the patient’s wishes evolve, the order can be updated to reflect those changes.
  • DNR orders are only for elderly individuals. This is a common myth. People of all ages may choose to have a DNR order based on their health conditions and personal beliefs. Age does not determine the need for or appropriateness of a DNR.
  • A DNR order will prevent you from receiving treatment in a hospital. Hospitals are required to respect DNR orders, but this does not mean that patients will be denied other necessary medical treatments. DNR orders apply specifically to resuscitation efforts.
  • You need a lawyer to create a DNR order. While legal assistance can be beneficial, it is not a requirement. Individuals can complete a DNR order form on their own, as long as it meets the state’s requirements.
  • Once signed, a DNR order is automatically honored everywhere. While DNR orders are recognized in many healthcare settings, it is essential to ensure that the order is communicated clearly to all healthcare providers. It is advisable to carry a copy of the DNR order and inform family members and caregivers.

By addressing these misconceptions, individuals can better understand their options and make informed choices regarding their medical care preferences. Open communication with healthcare providers and loved ones is key to ensuring that wishes are honored.

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