20 CAR pt. 82, Appendix A
NO CPR DO NOT RESUSCITATE DNR
STATE OF ARKANSAS EMERGENCY MEDICAL SERVICES DO NOT RESUSCITATE ORDER
Patient's Full Name: _
Signature of Patient or Health Care Proxy or Legal Guardian
Date
ATTENDING PHYSICIAN'S ORDER
I, the undersigned, state that I am the physician for the patient named above.
I hereby direct any and all qualified Emergency Medical Services personnel, commencing on the effective date noted below, to withhold cardiopulmonary resuscitation (cardiac compression, endotracheal intubation and other advanced airway management, artificial ventilation, defibrillation, administration of cardiac resuscitation medications, and related procedures) from the patient in the event of the patient's cardiac or respiratory arrest. I further direct such personnel to provide to the patient other medical interventions such as intravenous fluids, oxygen, or other therapies deemed necessary to provide comfort care or alleviate pain.
Signature of Attending Physician
Physician's Telephone number (emergency #)
Physician's Printed/Typed Name
Date Order Written