Attorney-Approved Do Not Resuscitate Order Document for Nebraska

Nebraska Do Not Resuscitate Order (DNR)

This document serves as a Do Not Resuscitate (DNR) order in accordance with the laws of the State of Nebraska, specifically adhering to the Nebraska Revised Statute § 20-404. It communicates the wishes of individuals regarding the refusal of resuscitation in the event of cardiac or respiratory arrest. The completion of this form should be carried out by the person named below, in consultation with a licensed healthcare provider, to ensure the individual’s medical preferences are understood and respected.

Patient Information

• Full Name: _________________________
• Date of Birth: _________________________
• Address: _________________________
• City: _________________________ State: Nebraska ZIP: _________________________

Medical Orders

This section defines specific medical orders related to resuscitation:

1. I, the undersigned, in accordance with Nebraska law, hereby direct any and all medical personnel to withhold or withdraw resuscitation attempts in the event of my cardiac or respiratory arrest.
2. This order is to remain in effect indefinitely unless revoked by me or my legally authorized representative in writing.

Signature

To ensure the validity of this Do Not Resuscitate Order, the following signatures are required:

• Patient Signature (or Legally Authorized Representative): _________________________ Date: _________________________
• Relationship to Patient (if signed by Legally Authorized Representative): _________________________
• Witness Signature: _________________________ Date: _________________________
• Physician Signature: _________________________ Date: _________________________

This document confirms my explicit request that no measures be taken to resuscitate me in the event of cardiac or respiratory failure, understanding the implications of this request. I have discussed and completed this form with a licensed healthcare provider to ensure my wishes are clearly documented and will be honored by my healthcare team.

It is recommended that this document be discussed thoroughly with a healthcare provider to ensure all parties understand the individual's wishes regarding end-of-life care and that appropriate steps are taken to respect those wishes. Upon completion and signing, copies of this form should be made available to all relevant parties involved in the care of the individual.