Hawaii Do Not Resuscitate Order
This Do Not Resuscitate (DNR) Order is created in accordance with Hawaii state laws regarding advance healthcare directives. It is intended to express the wishes of the individual regarding resuscitation efforts in the event of a medical emergency.
Patient Information:
- Name: ______________________________
- Date of Birth: ______________________
- Address: ____________________________
- Phone Number: ______________________
Healthcare Provider Information:
- Name: ______________________________
- Address: ____________________________
- Phone Number: ______________________
Order Statement:
I, the undersigned, hereby declare that I do not wish to receive cardiopulmonary resuscitation (CPR) or other life-sustaining treatments in the event of cardiac or respiratory arrest.
Signature:
______________________________
Date:
______________________________
Witness Information:
- Name: ______________________________
- Signature: __________________________
- Date: ______________________________
This document must be signed in the presence of a witness who is not related to the patient or entitled to any portion of the patient’s estate.
For further guidance, please consult with a healthcare professional or legal advisor.