Free Do Not Resuscitate Order Document for the State of Kansas

Kansas Do Not Resuscitate Order

This document serves as a Do Not Resuscitate (DNR) Order in accordance with the specific statutes of the State of Kansas. It indicates the request of the undersigned individual, or their legally authorized representative, for no resuscitation to be performed in the event of cardiac or respiratory arrest. This document is governed by the relevant Kansas state laws, particularly those embodying patient rights and end-of-life care decisions.

The completion of this form affirms that a detailed discussion has taken place between the patient or their authorized representative and a licensed healthcare provider. This conversation ensures understanding of the implications, benefits, and potential consequences of this DNR Order.

Patient Information

• Full Name: __________________________________________
• Address: ____________________________________________
• City: ___________________ State: KS Zip: ___________
• Date of Birth: _______________ SSN (Optional): _____________

Order Information

I, or my legally authorized representative,

• Designation: _________________________________________
• Relationship to Patient: _______________________________
• Contact Number: _____________________________________

hereby request and consent to the Do Not Resuscitate Order as indicated by my signature or that of my authorized representative. This request is made after thorough consideration of all relevant aspects of my current health condition and prognosis.

Healthcare Provider Acknowledgment

This section must be completed by the licensed healthcare provider who has discussed the DNR Order with the patient or their representative, ensuring full understanding and voluntary consent.

• Provider's Name: __________________________________
• License Number: _________________________________
• Address: _________________________________________
• Contact Number: _________________________________

The healthcare provider confirms that the patient/legal representative has been fully informed and consents to this DNR Order. The provider has ensured that the DNR Order is appropriate based on the patient's health status and aligns with current medical standards and the patient's wishes.

Signature Section

The validity of this Kansas Do Not Resuscitate Order is contingent upon the signatures of the person making the declaration, or their legal representative, and the witnessing healthcare provider or notary public.

Patient/Representative Signature: _______________________________ Date: ____________

Healthcare Provider/Notary Signature: ___________________________ Date: ____________

This DNR Order remains valid indefinitely unless revoked by the patient or their legal representative. It is recommended that this document be reviewed periodically, especially after any significant change in the patient's health condition.