Kentucky Do Not Resuscitate Order Document

This Kentucky Do Not Resuscitate (DNR) Order Template is designed to reflect the wishes of individuals who, due to medical conditions, choose not to undergo cardiopulmonary resuscitation (CPR) in case their breathing or heartbeat stops. This document complies with the Kentucky Revised Statutes, specifically addressing directives for withholding life-prolonging treatment.

Kentucky Do Not Resuscitate (DNR) Order

Patient Information:

• Full Name: ___________________________
• Date of Birth: ___________________________
• Primary Physician: ___________________________
• Physician's Phone Number: ___________________________

By signing this document, the undersigned (patient) acknowledges their decision to refuse cardiopulmonary resuscitation (CPR), including but not limited to:

1. External chest compressions
2. Insertion of an artificial airway
3. Administration of resuscitation medications
4. Defibrillation
5. Provision of respiratory assistance by mechanical means

This decision is made in full understanding of the potential consequences, including the possibility of death. This order does not affect the provision of other types of medical interventions, such as pain relief, nutrition, and hydration, as deemed acceptable by the patient or their legal representative.

Consent:

• Patient Signature (or Legal Representative): ___________________________
• Date: ___________________________
• Relationship to Patient (if signed by Representative): ___________________________

Physician's Acknowledgment:

• Physician's Signature: ___________________________
• Date: ___________________________
• License Number: ___________________________

This Do Not Resuscitate Order is valid throughout the Commonwealth of Kentucky and should be reviewed regularly, especially if the patient's medical condition changes. Keeping a copy of this document with the patient and within the patient’s medical records is advised to ensure that the patient's wishes are respected.