Ind. Code § 16-36-5-15
An out of hospital DNR declaration and order must be in substantially the following form:
OUT OF HOSPITAL DO NOT RESUSCITATE DECLARATION AND ORDER
This declaration and order is effective on the date of execution and remains in effect until the death of the declarant or revocation.
OUT OF HOSPITAL DO NOT RESUSCITATE DECLARATION
Declaration made this ____ day of __________. I, _____________, being of sound mind and at least eighteen (18) years of age, willfully and voluntarily make known my desires that my dying shall not be artificially prolonged under the circumstances set forth below. I declare:
My attending physician, advanced practice registered nurse, or physician assistant has certified that I am a qualified person, meaning that I have a terminal condition or a medical condition such that, if I suffer cardiac or pulmonary failure, resuscitation would be unsuccessful or within a short period I would experience repeated cardiac or pulmonary failure resulting in death.
I direct that, if I experience cardiac or pulmonary failure in a location other than an acute care hospital or a health facility, cardiopulmonary resuscitation procedures be withheld or withdrawn and that I be permitted to die naturally. My medical care may include any medical procedure necessary to provide me with comfort care or to alleviate pain.
I understand that I may revoke this out of hospital DNR declaration at any time by a signed and dated writing, by destroying or canceling this document, or by communicating to health care providers at the scene the desire to revoke this declaration.
This declaration was signed by me and by the witnesses in compliance with Indiana law and by: [Initial or check only one (1) of the following spaces]
__ Signing on paper or electronically in each other's direct physical presence.
__ Signing in separate counterparts on paper using two (2) way, real time audiovisual technology.
__ Signing electronically using two (2) way, real time audiovisual technology or telephonic interaction.
__ Signing in separate counterparts on paper using telephonic interaction between me (the declarant) and all witnesses.
I understand the full import of this declaration.
Signed___________________________________ |
Printed name______________________________ |
_________________________________________ |
City and State of Residence___________________ |
IF THE DECLARANT IS INCAPACITATED OR INCOMPETENT, the adult who signed above for the declarant is the: [Initial or check only one (1) of the following spaces]
__ Court appointed guardian of the declarant's person.
__ Agent or attorney in fact (POA) under the declarant's heath care power of attorney.
__ Health care representative for the declarant under a written advance directive or other written appointment.
__ Proxy for the declarant (state relationship to declarant) _________________________
Address and other optional contact information for guardian, agent, representative, or proxy who signed for the declarant:
_______________________________________________________
________________________________________________________
The declarant is personally known to me, and I believe the declarant to be of sound mind. I did not sign the declarant's signature above, for, or at the direction of, the declarant. I am not a parent, spouse, or child of the declarant. I am not entitled to any part of the declarant's estate or directly financially responsible for the declarant's medical care. I am competent and at least eighteen (18) years of age.
Witness____________Printed name___________Date__________
Witness____________Printed name___________Date__________
OUT OF HOSPITAL DO NOT RESUSCITATE ORDER
I,___________________, the attending physician, advanced practice registered nurse, or physician assistant of _________________, have certified the declarant as a qualified person to make an out of hospital DNR declaration, and I order health care providers having actual notice of this out of hospital DNR declaration and order not to initiate or continue cardiopulmonary resuscitation procedures on behalf of the declarant, unless the out of hospital DNR declaration is revoked.
Signed_____________________Date__________ |
Printed name______________________________ |
Physician/APRN/PA license number ___________ |
________________________________________ |
IC 16-36-5-15