Official Montana Do Not Resuscitate Order Template

Montana Do Not Resuscitate (DNR) Order

This document serves as a Do Not Resuscitate Order, specific to the state of Montana, in accordance with the relevant sections of the Montana Code Annotated (MCA). It is a legally binding document that indicates an individual's wish not to receive cardiopulmonary resuscitation (CPR) in the event the individual's heart stops or if the individual stops breathing.

Patient Information

Please fill in the form below with the patient's information:

• Full Name: ________________________________________
• Date of Birth (MM/DD/YYYY): _________________________
• Address: __________________________________________
• City: ___________________ State: Montana ZIP: ________

Medical Information

Details concerning the medical condition that prompts this order:

• Primary Physician's Name: ___________________________
• Primary Physician's Contact Information: _______________
• Specific Medical Condition(s): _________________________

DNR Order Declaration

I, __________________________ (patient's name), hereby declare my decision to forgo resuscitation efforts in the event of cardiac or respiratory arrest. This decision is made freely and voluntarily, with a full understanding of the nature of CPR and the consequences of a Do Not Resuscitate Order.

Legal Guardian or Healthcare Surrogate Information (if applicable)

If the patient is unable to make medical decisions, the legal guardian or designated healthcare surrogate must fill out this section:

• Name: _____________________________________________
• Relationship to Patient: ____________________________
• Contact Information: _______________________________

Signature Section

This Do Not Resuscitate Order will not be effective without the required signatures:

1. Patient's Signature (or Legal Guardian/Healthcare Surrogate's Signature): _____________________ Date: ___________
2. Witness Signature: _______________________________________ Date: ___________
3. Primary Physician's Signature: ____________________________ Date: ___________

By signing, all parties acknowledge and respect the patient's wishes as documented in this Do Not Resuscitate Order.

Instructions for Revocation

A Do Not Resuscitate Order can be revoked by the patient or the patient’s legal representative at any time through the following methods:

• A verbal indication to cease the DNR order to the attending physician or medical personnel.
• A written revocation of the DNR order.
• Physical destruction of the DNR order document.

It is essential for all parties involved to communicate clearly and ensure the patient's wishes are honored throughout their care.