Maine Do Not Resuscitate Order
This document serves as a Do Not Resuscitate (DNR) Order in accordance with the relevant laws of the State of Maine. It signals healthcare providers that the individual named below does not want any form of resuscitation attempted in the event that their breathing stops or their heart ceases to beat.
Please complete all sections for the DNR Order to be valid.
Patient Information
- Patient Name: ___________________________________
- Date of Birth: ___________________________________
- Address: _________________________________________
- City: ____________________ State: ME Zip: _________
- Phone Number: ____________________________________
Medical Information
This order is based on the patient's medical condition and desire to allow natural death. Check all conditions that apply:
- _____ Terminal Illness
- _____ Irreversible coma or vegetative state
- _____ Other: ________________________________________________
DNR Order
I, ________________________ (patient or legally authorized person), upon advice of the physician, Dr. _____________________________, do not wish to have cardiopulmonary resuscitation (CPR), including any form of life-sustaining treatment such as mechanical ventilation, defibrillation, use of medications to restart the heart, or intubation. This order does not prevent the patient from receiving other medical treatments deemed necessary, including pain relief, oxygen, and other comfort cares.
Physician Information
- Physician's Name: ___________________________________
- License Number: ____________________________________
- Phone Number: _____________________________________
- Address: ___________________________________________
- City: ____________________ State: ME Zip: _________
Signature Section
This order will only be considered valid when it is signed and dated by the following:
- The patient or their legally authorized representative
- The attending physician
By signing this document, you acknowledge your understanding of its contents and the implications of a DNR order.
- Patient/Legally Authorized Representative Signature: _____________________________ Date: ____________
- Physician Signature: _____________________________ Date: ____________
This document is compliant with the laws of Maine and should be placed in the patient's medical record and kept in a location where it can be easily accessed by medical professionals.
