Patient Name
Date of Birth
Medical Record Number
A. Cardiopulmonary Resuscitation (CPR):
Attempt Resuscitation/CPR
Do Not Attempt Resuscitation (DNR)
B. Medical Interventions:
Full Treatment
Selective Treatment
Comfort-Focused Treatment
C. Artificially Administered Nutrition:
Long-term artificial nutrition
Trial period of artificial nutrition
No artificial nutrition
D. Additional Orders or Instructions:
Physician Signature
Date
Physician Name (Print)
Phone Number
Patient / Surrogate Signature
Date