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In New Jersey, the Do Not Resuscitate (DNR) Order form plays a critical role in health care planning, allowing individuals to make important decisions about their end-of-life care. The form communicates a person’s wish not to have cardiopulmonary resuscitation (CPR) performed on them in the event their heart stops or they stop breathing. This order is a key component for those who want to ensure their medical treatment aligns with their wishes, particularly when they are unable to communicate these preferences themselves. It must be completed after careful discussion with a health care provider, reflecting a person's values and health care goals. Recognizing its significance, the state requires the form to be filled out clearly and accurately, ensuring that it is easily understood by all healthcare professionals involved. By making decisions about CPR in advance, individuals give a valuable gift to their loved ones: clarity and peace of mind during difficult times.
Sample - New Jersey Do Not Resuscitate Order Form
New Jersey Do Not Resuscitate (DNR) Order Template
This template is designed to assist in documenting a patient's wish not to have cardiopulmonary resuscitation (CPR) in the event that their breathing stops or their heart stops beating. This document should be completed following the guidelines established by New Jersey state laws. It is crucial for ensuring that the patient's wishes are respected and followed by healthcare providers.
Patient Information:
- Patient's Name: _____________________________________
- Patient's Date of Birth: ____________________________
- Patient's Address: __________________________________
- State of New Jersey Identification Number (if applicable): __________________
Medical Information:
- Primary Diagnosis: ___________________________________
- Relevant Medical History: ____________________________
- Attending Physician Name: ____________________________
- Physician License Number: ____________________________
This Do Not Resuscitate Order is based upon the patient’s medical condition and their personal wishes. It is only valid within the State of New Jersey and should be followed by all New Jersey healthcare providers. This order does not affect the provision of other medical treatments, such as pain relief, nutrition, or respiratory support.
Patient or Legally Authorized Representative Declaration:
I, _______________________________ (Patient/Legally Authorized Representative), hereby declare that I understand the full implications of this Do Not Resuscitate Order. I am aware that this means in the event of a cardiac or respiratory arrest, no medical interventions such as CPR will be attempted to revive me. I have discussed my options with my healthcare provider and understand the consequences of this order. This decision is made voluntarily and without any coercion.
Date: ________________________
Signature: ________________________
Physician’s Statement:
I, ________________________ (Physician's Name), license number ____________________, certify that the above-named patient has a significant medical condition that justifies a Do Not Resuscitate Order and that the patient (or their legally authorized representative) has given informed consent for this order. This order complies with all applicable laws and regulations in the State of New Jersey.
Date: ________________________
Signature: ________________________
This order should be reviewed annually and updated as necessary. It should be kept in a location where it can be easily accessed by emergency responders or healthcare providers.
PDF Form Specifics
| Fact Name | Detail |
|---|---|
| Purpose | The New Jersey Do Not Resuscitate Order form is used to indicate that a person does not want to be revived through cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest. |
| Governing Law | This form is governed by New Jersey statutes, particularly under the "Practitioner Orders for Life-Sustaining Treatment Act" or POLST, as part of broader New Jersey health care directives laws. |
| Who Can Sign | The form must be signed by a licensed physician, advanced practice nurse, or physician assistant, indicating that the individual’s medical condition warrants a DNR order, alongside the signature of the patient or their legally authorized representative. | .
| Revocation | The DNR order can be revoked at any time by the patient or their legally authorized representative, through a verbal or written statement or by physically destroying the DNR form. |
| Effectiveness Across Settings | |
| Identification | Patients with a DNR order may wear a DNR bracelet or necklace, or carry a card to alert health care professionals to the existence of the DNR order. |
Detailed Steps for Using New Jersey Do Not Resuscitate Order
When preparing a New Jersey Do Not Resuscitate (DNR) Order form, it is crucial to handle the document with precision and care, ensuring all required information is filled accurately and completely. A DNR order is a binding legal document that instructs healthcare providers not to perform cardiopulmonary resuscitation (CPR) in the event a patient stops breathing or their heart stops beating. This document is typically prepared by individuals in consultation with their healthcare providers, reflecting the individual's wishes regarding end-of-life care. Given its sensitivity and significance, filling out the DNR order correctly is paramount. Here are detailed instructions to guide you through the process.
- Start by entering the patient's full legal name, including first, middle, and last names, to ensure there is no confusion regarding the individual's identity.
- Fill in the patient's date of birth, providing a clear reference to the patient’s age and helping to further ensure accurate identification.
- Include the patient's address, specifying the street name, number, city, state, and ZIP code, to complete the personal identification details required on the form.
- Document the name and contact information of the patient's primary physician. This includes the physician's full name, phone number, and address. This step is crucial for verification and consultation purposes.
- Ensure the patient or their legally authorized representative reads the statement acknowledging understanding of what the DNR order represents. This acknowledgment is an essential part of the form, indicating informed consent.
- Have the patient or their legally authorized representative sign the form. If the patient is unable to sign, a representative, as per New Jersey law, can sign on their behalf. Always include the date of signing to validate the form.
- The patient’s physician must also sign the form, confirming the DNR order's medical appropriateness for the patient’s condition. The physician’s signature and the date of signing are both mandatory.
Filling out a New Jersey DNR order is a straightforward process, but it demands attention to detail to ensure all parts of the document are completed accurately. This ensures the patient's wishes are clearly communicated and can be respected by healthcare providers. It’s important to review the form thoroughly before submitting it to ensure no sections have been missed and that all information is correct. Once completed, the DNR order should be kept in a location where it can be easily accessed by family members and healthcare providers in the event it needs to be presented quickly.
Learn More on New Jersey Do Not Resuscitate Order
What is a Do Not Resuscitate (DNR) Order in New Jersey?
A Do Not Resuscitate (DNR) Order in New Jersey is a medical directive that tells health care providers not to perform cardiopulmonary resuscitation (CPR) if a patient's breathing stops or if the patient's heart stops beating. It is a decision made by a patient or their authorized surrogate when the focus of care is on comfort rather than prolonging life.
Who can request a DNR Order in New Jersey?
In New Jersey, a DNR Order can be requested by:
- An adult patient who is capable of making their own health care decisions.
- A legal guardian or health care proxy acting on behalf of a patient who is unable to make decisions.
- A close family member or friend, in the absence of a designated representative, if the patient is unable to communicate their wishes.
How can one obtain a DNR Order in New Jersey?
To obtain a DNR Order in New Jersey, the patient or their representative must have a discussion with the attending physician. The physician must agree that a DNR is appropriate based on the patient's medical condition and wishes. The order is then documented in the patient's medical record and, in some cases, on a wallet-sized card that the patient can carry.
Is the DNR Order applicable outside of a hospital setting?
Yes, New Jersey's DNR Orders are applicable both in healthcare facilities and in non-hospital settings, such as the patient's home or in a hospice. It is vital for patients and their families to inform all caregivers and potentially first responders about the existence of a DNR Order to ensure it is followed.
Can a DNR Order be revoked or changed?
Yes, a DNR Order can be revoked or changed at any time by the patient or their authorized surrogate. This can be done by informing the healthcare provider verbally or in writing. A new DNR Order must be completed and signed if the patient or proxy wishes to change the directives previously given.
What happens if there is no DNR Order in place during an emergency?
If no DNR Order is present during an emergency, medical personnel are legally obligated to perform all necessary lifesaving measures, including CPR, unless directed otherwise. This underscores the importance of having a DNR Order clearly documented and readily available if this aligns with the patient's wishes.
Are there legal implications for health care providers who follow a DNR Order?
Health care providers in New Jersey are legally protected when they follow a validly executed DNR Order. State laws provide immunity from criminal, civil, or disciplinary penalties as long as the health care professionals act in good faith and in accordance with the patient's directives. However, it is crucial for health care providers to ensure that the DNR Order is current and accurately reflects the patient's wishes.
Common mistakes
When filling out the New Jersey Do Not Resuscitate (DNR) Order form, it's crucial to pay close attention to detail and to follow instructions carefully. Here are eight common mistakes that people often make during this process:
Not checking the identity of the patient carefully, which includes ensuring that the patient's full name and date of birth are accurately entered. Mistakes in this area can lead to confusion or misapplication of the DNR.
Failure to have the form signed by the required parties. The DNR order needs to be signed by both the patient (or their legal healthcare proxy) and the attending physician to be valid. Missing signatures can invalidate the document.
Skipping the date of when the DNR order was signed. The date provides a timeline that is crucial for the order's implementation and validity.
Omitting detailed contact information for the patient and the physician. This information is essential for any necessary follow-up and to ensure that the DNR order can be verified by healthcare professionals.
Misunderstanding the scope of the DNR order. Some individuals mistakenly believe that a DNR order covers more than it actually does, such as medical interventions not related to resuscitation. It's important to understand and clearly specify what the DNR covers.
Failing to review and update the form as needed. As the patient's condition changes, or if the patient's wishes change, the DNR order should be reviewed and possibly revised to reflect current wishes and medical advice.
Not making sufficient copies or ensuring that the DNR order is easily accessible. The order should be readily available to healthcare providers and family members to make certain that the patient's wishes are honored.
Using a form that is not recognized by New Jersey state law. It’s critical to use the proper form, as each state has its own requirements for DNR orders to be considered valid.
Avoiding these mistakes can help ensure that the Do Not Resuscitate order is accurately completed and will be respected by healthcare professionals and caregivers. It is also advisable to seek guidance from healthcare professionals or legal advisors when filling out a DNR to ensure all aspects are correctly addressed.
Documents used along the form
The New Jersey Do Not Resuscitate (DNR) Order is an important document for individuals who wish to express their desire to forego resuscitative efforts in the event of a cardiac or respiratory arrest. While a DNR form is critical in ensuring a patient's wishes are respected, there are several other documents and forms that frequently accompany it to provide a comprehensive approach to end-of-life planning. These documents further clarify a person’s preferences for treatment and ensure their healthcare decisions are honored.
- Advanced Healthcare Directive (Living Will): This legal document outlines a person's preferences for medical treatments and interventions in scenarios where they're unable to make decisions for themselves. It can specify which, if any, life-sustaining treatments, such as mechanical ventilation or tube feeding, an individual desires in critical health situations.
- Medical Orders for Life-Sustaining Treatment (MOLST) Form: Similar to the DNR order, the MOLST form provides detailed instructions regarding a wide range of life-sustaining treatments, including CPR, intubation, mechanical ventilation, and artificial nutrition and hydration. This form is used by individuals facing serious health conditions, detailing their preferences for treatments in emergency and non-emergency situations.
- Healthcare Proxy or Power of Attorney: A legal document that designates another individual (a proxy or agent) to make healthcare decisions on behalf of the person should they become incapacitated or unable to communicate their wishes. This includes decisions about starting, stopping, or refusing treatment.
- HIPAA Authorization Form: This document allows healthcare providers to disclose protected health information to designated persons who are not legally authorized to make health care decisions for the patient. It is crucial for ensuring loved ones have access to necessary health information to make informed decisions on the patient's behalf.
These documents, when used together with the New Jersey DNR Order, create a protective network to ensure that an individual's health care preferences are thoroughly documented and respected across different medical scenarios. It's advisable for individuals to consult with healthcare professionals and possibly a legal advisor to understand these documents fully and to ensure they are executed correctly. Proper completion and distribution of these documents are crucial in ensuring that healthcare teams can honor those wishes efficiently and respectfully.
Similar forms
A New Jersey Do Not Resuscitate (DNR) order form is similar to an Advance Directive. Both documents allow individuals to make decisions about their healthcare in advance, but while a DNR specifically instructs emergency medical personnel not to perform CPR if the patient's breathing or heart stops, an Advance Directive can provide more comprehensive instructions about a wider range of medical treatments and interventions beyond CPR. This might include, for instance, whether to use ventilators, feeding tubes, or other life-sustaining measures.
Much like a Medical Power of Attorney, a New Jersey DNR shares the characteristic of allowing someone to make critical healthcare decisions on another's behalf, albeit more narrowly focused. While a Medical Power of Attorney designates a healthcare proxy to make all decisions about personal healthcare when the person cannot make decisions themselves, a DNR strictly limits the scope to the non-initiation of CPR in life-threatening situations. Both documents are vital in planning for healthcare emergencies and ensuring that the individual's wishes are respected.
The New Jersey DNR is also akin to a Living Will. Both forms are used to dictate healthcare preferences ahead of time, with a Living Will generally providing instructions on refusing or requesting certain types of medical care or treatments in certain situations where the individual is unable to communicate. The DNR, by contrast, is expressly for instructing healthcare professionals not to administer CPR in the event of cardiac or respiratory arrest.
Comparable to the Physician Orders for Life-Sustaining Treatment (POLST) form, the DNR provides specific instructions regarding end-of-life care. The POLBrokerST, broader in scope than a DNR, is a medical order that details a wide range of preferences about end-of-life care, including CPR, intubation, mechanical ventilation, artificial nutrition, and hydration. While the POLST encompasses a broader range of medical orders, the DNR is strictly limited to the desire not to have CPR performed.
The DNR order similarly aligns with the Health Care Proxy form in its function to communicate wishes regarding medical treatment. Although the Health Care Proxy primarily designates another person to make healthcare decisions across various scenarios, it can include specific wishes such as those outlined in a DNR. The fundamental difference lies in the breadth of decision-making power; whereas the Health Care Proxy can cover a comprehensive range of medical decisions on behalf of the patient, the DNR order specifically addresses the use of CPR in life-threatening situations.
Dos and Don'ts
Filling out a New Jersey Do Not Resuscitate (DNR) Order form is an important step for those who wish to make their health care wishes known in advance. There are specific things you should do and avoid doing to ensure your form is valid and reflects your true intentions. Below are some tips to guide you through this process.
Things you should do:
- Review the form carefully. Make sure you understand each section before filling it out. Don't hesitate to ask a healthcare provider for clarification if needed.
- Fill out the form accurately. Provide precise and clear information to avoid any misunderstandings about your wishes.
- Discuss your decision with your family and healthcare provider. It's important that those close to you and those who will be involved in your care understand your wishes.
- Sign and date the form in the presence of a witness. New Jersey law requires your signature and the signature of a witness to make the DNR order valid.
- Make copies of the completed form. Give a copy to your primary healthcare provider, close family members, and keep one with your important papers. It's also a good idea to carry a copy with you.
Things you shouldn't do:
- Leave sections blank. If a section does not apply to you, enter "N/A" (not applicable) instead of leaving it blank to show you didn’t overlook it.
- Use ambiguous language. Be clear and specific about your wishes to avoid any potential confusion or misinterpretation.
- Forget to update the form as necessary. If your wishes change, or if there are significant changes in your health, a new form should be filled out to reflect these changes.
- Sign without a witness. A witness's signature is essential for the validity of the form; make sure this step is not skipped.
- Fail to inform your healthcare provider of your DNR order. Ensure your doctor is aware of and has a copy of your completed DNR form. This is crucial for your wishes to be followed accurately.
Misconceptions
When discussing the New Jersey Do Not Resuscitate (DNR) Order form, several misconceptions commonly arise. These misunderstandings can lead to confusion and anxiety among patients and their families. Addressing these misconceptions is vital to ensure that individuals can make informed choices about their healthcare preferences.
Only the elderly or terminally ill can have a DNR order. This is a widespread misconception. In reality, New Jersey allows any individual, regardless of age or current health status, to have a DNR order, provided they are competent to make such a decision or have a legal healthcare representative who can decide on their behalf. The decision to have a DNR order is based on personal values and medical advice, not age or health criteria.
A DNR order means no medical intervention will be provided. This misunderstanding can cause unnecessary worry. A DNR order specifically refers to not performing cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest. It does not mean that other forms of medical care will be withheld. For example, patients with a DNR order can still receive antibiotics, pain management, and other supportive treatments.
The form must be filled out by a doctor. While it's true that a physician or an advanced practice nurse must sign the DNR order in New Jersey for it to be valid, the initiation of the conversation and the decision can come from the patient or their healthcare proxy. The medical professional's role is to ensure the patient or their representative understands the implications of a DNR order and to document the decision formally.
Once signed, a DNR order is permanent. This is not the case. A DNR order can be revoked at any time by the patient or their designated healthcare representative. The decision to have a DNR order should be continuously evaluated and discussed with healthcare providers, especially if there are changes in the patient's medical condition or treatment preferences. Revocation simply requires informing the healthcare team of the change in decision.
Understanding these nuances allows individuals and their families to navigate their healthcare choices more effectively, ensuring that decisions align with their wishes and values.
Key takeaways
Filling out and using the New Jersey Do Not Resuscitate (DNR) Order form involves several key aspects that individuals should be aware of. This document is crucial for those who wish to express their wishes regarding resuscitation in situations where they cannot communicate their preferences. Here are seven key takeaways:
- The New Jersey DNR Order must be completed and signed by a licensed physician. The physician's signature indicates that they have discussed the decision and its implications with the patient or the patient's legal healthcare representative.
- Patients or their authorized healthcare representative have the right to participate in the decision-making process regarding the DNR Order. This emphasizes the importance of communication and ensures that the patient's wishes are respected.
- It is essential to keep the completed DNR Order in a visible and accessible location. In case of an emergency, healthcare providers need to be able to quickly locate the document to comply with the patient's wishes.
- The form should be reviewed periodically. The preferences of patients may change over time, as might their medical condition. Thus, revisiting and, if necessary, revising the DNR Order is crucial.
- Copying the signed DNR Order is permitted. Copies have the same legal effect as the original, which allows the document to be easily shared with all healthcare providers involved in the patient's care.
- Emergency Medical Services (EMS) personnel are legally obligated to follow valid DNR Orders. This ensures that the patient's wishes regarding resuscitation are respected even in emergency situations outside of a hospital setting.
- Revocation of the DNR Order can occur at any time by the patient or their legal healthcare representative. This decision must be communicated to the physician and all relevant healthcare providers immediately.
Understanding these key points ensures that individuals can make informed decisions regarding their medical care and ensures that those decisions are respected by healthcare professionals in New Jersey.
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