New Legal Forms

OKLAHOMA DO-NOT-RESUSCITATE (DNR)CONSENT FORM

(Front or First Page)

OKLAHOMA DO-NOT-RESUSCITATE (DNR)PHYSICIAN CERTIFICATION AND ORDER

OKLAHOMA DO-NOT-RESUSCITATE (DNR)COMPLIANCE FORM

(Back or Second Page)

This form may only be signed by the patient or the patient’s Legal Representative if the patient’s Legal Representative has been

appointed by:(a) Health care proxy under a properly

activated Living Will/Advance Directive that authorizes such power

(b) The patient’s attorney-in-fact under a validly executed DPOA for healthcare that authorizes such action OR

(c) Guardian under a court order with the specific authorization to make DNR decisions on a patient’s behalf.

If relying on a Legal Representative, the DNR Compliance Form (Second Page) must be

completed.

HOW TO COMPLETE

• If the patient is signing the form, the patient signs the first page only

• If the Legal Representative meets above criteria the Legal Representative will sign the first page; the Physician and Legal Representative must also sign the second page

• DNR status must be ordered in the EMR; the form must be scanned into the EMR and a copy of the form must be placed in the patient’s chart.

This is a legal document in the state of Oklahoma and is valid for use throughout

the state and other facilities.

BASED ON CLEAR AND CONVINCING CERTIFICATION OF PHYSICIAN

The top part of the front of this form is for the Physician to complete.

This form is completed when a family, a family member, friends, caregivers, or previous healthcare providers provide clear and convincing

evidence that a patient (who is incapacitated and lacks a legal representative) would not have chosen or wanted resuscitation measures

(CPR) in his or her current state.

HOW TO COMPLETE

• The Physician signs the top portion of the first page of this form• DNR status must be ordered in the EMR; the form must be scanned into

the EMR and a copy of the form must be placed in the patient’s chart• OPTIONAL: Family members may document the reasons this patient

would consent to a natural death and refuse cardiopulmonary resuscitation-see Family Section (optional) below

OR• The green form does not need to be completed if the Physician

documents in his or her clinical note in the EMR:(a) The conversation with the patient’s family members, health care providers, or others AND(b) Articulate the reasons and evidence given by these parties

BASED ON FUTILITY AND IMMINENT DEATH

The bottom part of the front of this form is for the Physician to complete.

This form is completed when an attending physician, in his or her reasonable medical judgment, believes that CPR is medically futile and

inappropriate or unreasonable because this patient’s death is imminent – hours or days. (INTEGRIS System Ethics Policy 106 DNR: 2.3)

HOW TO COMPLETE

The Physician:• Signs the bottom portion of the front of this form• DNR status must be ordered in the EMR; the form must be scanned

into the EMR and a copy of the form must be placed in the patient’s chart.

OR• The green form does not need to be completed if the Physician

documents in his or her clinical note in the EMR:• (a) Administration of CPR would be Medically Inappropriate because

CPR (i) will not prevent imminent death and (ii) will cause undue harms, burdens, and risks – without any benefits – to the patient

FAMILY SECTION (optional)

The back of the form is an optional section where family members may document the reasons this patient would consent to a natural death and

refuse cardiopulmonary resuscitation.

Use the YELLOW DNR CONSENT FORM when the patient can sign their own DNR or has a valid Legal Representative (healthcare proxy, attorney-in-fact for healthcare decisions, or a legal guardian)!

The physician will use the GREEN DNR ORDER FORM only when a yellow DNR consent form has not been signed!

How to contact Legal Services:

Day Shift (M-F office hours): INTEGRIS Baptist Medical Center – Susan Henderson 951-4779 or INTEGRIS Baptist Medical Center – Jody Joiner 951-4778 INTEGRIS Southwest Medical Center – Mary Daniel 951-4788 INTEGRIS Canadian Valley Hospital – Jody Joiner 951-4778 INTEGRIS Health Edmond – Aletheia Lawry 951-4781 INTEGRIS Bass Baptist Health Center – Allison Petersen 951-4787 INTEGRIS Baptist Regional Health Center (Miami) - Mary Daniel 951-4776 INTEGRIS Grove General Hospital - Mary Daniel 951-4776 Lakeside Women’s Hospital – Allison Petersen 951-4787

Evenings and Night Shift: 1st ask house supervisor, then may page Legal Services at 559-3907

Oklahoma Advance Directive for Health Care Planning

Outline for Oklahoma Advance Directive for Health Care Planningis a guide to help clinical staff explain the Oklahoma Advance Directive for Health

Care Planning to patients and to assist them in filling it out.