Free Do Not Resuscitate Order Document for Colorado

Colorado Do Not Resuscitate Order

This document serves as a legally binding Do Not Resuscitate (DNR) Order in accordance with Colorado's specific state laws guiding such directives. By completing this form, the individual named as the patient directs medical professionals to refrain from performing cardiopulmonary resuscitation (CPR) in the event the patient suffers from a cardiac or respiratory arrest.

Please provide the following information accurately:

Patient Information:

• Patient's Full Name: ____________________________
• Date of Birth: ____________________________
• Address: ____________________________
• City: ____________________________
• State: Colorado
• ZIP Code: ____________________________

Medical Provider Information:

• Physician's Full Name: ____________________________
• Physician's License Number: ____________________________
• Address: ____________________________
• City: ____________________________
• State: ____________________________
• ZIP Code: ____________________________
• Contact Phone Number: ____________________________

State-Specific Directive:

In accordance with the Colorado End-of-Life Options Act, this Do Not Resuscitate Order recognizes the patient's right to make autonomous health care decisions, including the refusal of resuscitation attempts in the event of cardiac or respiratory failure.

Patient or Legally Authorized Representative Signature:

I, the undersigned, assert that this Do Not Resuscitate Order reflects my explicit wishes or the wishes of the individual for whom I am legally authorized to make health care decisions. I understand that this order will direct health care providers to withhold CPR, including chest compressions, ventilations, and defibrillation, in the event of my cardiac or respiratory arrest.

• Patient/Legal Representative Signature: ____________________________
• Date: ____________________________

Physician Signature:

By my signature below, I affirm that the patient has fully understood the implications of executing a Do Not Resuscitate Order and is of sound mind to make such a directive. I confirm that this order complies with Colorado state laws and medical standards guiding end-of-life care decisions.

• Physician Signature: ____________________________
• Date: ____________________________

Notice:

This Do Not Resuscitate Order is legally binding throughout Colorado and must be respected by all healthcare professionals and emergency personnel. However, it is the patient’s responsibility to ensure that this document is presented or made known to healthcare providers in a timely manner. This order can be revoked at any time by the patient or their legally authorized representative.