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Windmill Center, 1259 N. Rainbow Dr., Ste. 300, Derby, Kansas 67037

NEWSLETTER                                                                                                                                                                                                                                   DECEMBER 2021

TO DNR OR TO NOT DNR

It is not uncommon for a new client to come in and see me to discuss estate planning and during our conversation the topic of a Do Not Resuscitate (DNR) comes up. Kansas does have a pre-hospitalization DNR request form. What does it cover? If your heart stops beating or you stop breathing, then no medical procedure to revive you will be instituted.

            When I’m asked “what if there is a chance I can be saved?” That’s not a decision for me to make. So in order to take the guesswork out of it, here is the pre-hospitalization Do Not Resuscitate (DNR) request form right out of the statute book.

            I, John Doe, request limited emergency care as herein described:

            I understand DNR means that if my heart stops beating or if I stop breathing, no medical procedure to restart breathing or heart functioning will be instituted.

            I understand this decision will not prevent me from obtaining other emergency medical care by pre-hospital care providers or medical care directed by a physician prior to my death.

            I understand I may revoke this directive at any time.

            I give permission for this information to be given to the pre-hospital care providers, doctors, nurses or other health care personnel as necessary to implement this directive.

            I hereby agree to the “Do Not Resuscitate” (DNR) directive.

______________________________________                    ___________________________
Signature                                                                                Date

______________________________________                    ___________________________
Witness                                                                                   Date

            I AFFIRM THIS DIRECTIVE IS THE EXPRESSED WISH OF THE PATIENT, IS MEDICALLY APPROPRIATE, AND IS DOCUMENTED IN THE PATIENT’S PERMANENT MEDICAL RECORD.

            In the event of an acute cardiac or respiratory arrest, no cardiopulmonary resuscitation will be initiated.

______________________________________                    ___________________________
Attending Physician’s Signature*                                          Date

______________________________________                    ___________________________
Address                                                                                   Facility or Agency Name

            *Signature of physician not required if the above-named is a member of a church or religion which, in lieu of medical care and treatment, provides treatment by spiritual means through prayer alone and care consistent therewith in accordance with the tenets and practices of such church or religion.

REVOCATION PROVISION

            I hereby revoke the above declaration.

______________________________________                    ___________________________
Signature                                                                                Date

            Now that I’ve confused everyone, I’ll quit while I’m ahead.

            Thanks,

            Mike

“Without education, you are not going anywhere in this world.”

Malcolm X

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