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Homepage ⇨ Attorney-Approved Wisconsin Do Not Resuscitate Order Document
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In Wisconsin, the Do Not Resuscitate (DNR) Order form serves as a vital document for individuals who wish to make their end-of-life wishes known, particularly regarding resuscitation efforts in the event of a medical emergency. This form allows patients to communicate their preferences about receiving cardiopulmonary resuscitation (CPR) and other life-saving measures. It is designed to ensure that healthcare providers respect the patient's wishes, especially in situations where the patient may be unable to express their desires verbally. The form must be completed and signed by both the patient and their physician, making it a collaborative effort that involves careful consideration of the individual's health status and personal values. Importantly, the DNR Order is recognized by emergency medical services, ensuring that first responders are aware of the patient's wishes when they arrive on the scene. Additionally, it is crucial for individuals to discuss their decisions with family members and loved ones to avoid confusion during critical moments. Understanding the nuances of this form can empower individuals to take control of their healthcare decisions and ensure that their preferences are honored in times of need.

Form Example

Wisconsin Do Not Resuscitate Order Template

This Wisconsin Do Not Resuscitate (DNR) order is designed in accordance with the specific requirements set by Wisconsin state laws. It is intended for individuals who wish to decline life-sustaining treatments in the event of a cardiac or respiratory arrest. Please complete the information below to create your personalized DNR order.

Personal Information

  • Full Name: ____________________________________
  • Date of Birth: _________________________________
  • Address: _______________________________________
  • City: __________________________________________
  • State: Wisconsin
  • Zip Code: _____________________________________

Emergency Contact Information

  • Contact Name: __________________________________
  • Relationship: ___________________________________
  • Phone Number: __________________________________

In accordance with the Wisconsin Do Not Resuscitate Law, I request to not be resuscitated in the event of cardiac or respiratory arrest. This request includes the withholding of:

  1. Cardiopulmonary resuscitation (CPR)
  2. Advanced airway management
  3. Artificial ventilation
  4. Defibrillation
  5. Administration of resuscitation drugs

This DNR order is valid immediately upon signing and remains in effect until legally revoked or if I am admitted to a hospital where this DNR order will be reviewed.

Signature

  • Patient Signature: ______________________________ Date: _______________
  • Physician Signature: ___________________________ Date: _______________
  • Witness Signature: _____________________________ Date: _______________

This document is not a substitute for legal advice. Consider consulting a lawyer to ensure that this DNR order is appropriately executed and to understand its implications fully.

➤ PDF File

File Specifications

Fact Name Details
Governing Law The Wisconsin Do Not Resuscitate Order form is governed by Wisconsin Statutes, Chapter 154.
Eligibility Any adult can complete the Do Not Resuscitate Order form, and it must be signed by a physician.
Form Validity The order remains valid until revoked by the patient or their legal representative.
Emergency Services Emergency medical personnel must honor the Do Not Resuscitate Order in Wisconsin, provided it is properly completed.
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