North Carolina Do Not Resuscitate Order (DNR) Form

The North Carolina Do Not Resuscitate Form is a document that allows the patient to prevent doctors from giving them CPR treatment in the case of a heart attack or when their lungs stop functioning. Thus, the form is beneficial for patients who want to provide themselves with comfortable conditions for passing away without attempts to save them. In case of completing the form, all the medical staff are acknowledged about that fact, so the patient can rest assured that they will not be subjected to harsh treatment.

Which Procedures does the DNR Form Include?

The form covers the situations of the patient’s cardiopulmonary attack (heart or lung attack).

It restrains the North Carolina Medical Association and EMS staff (emergency medical services) from engaging in such treatment as:

  • chest compression (CPR)
  • defibrillation
  • endotracheal intubation
  • assisted ventilation (breathing)
  • any types of stimulating drugs (stimulants)

However, the DNR form cannot stop the physicians from providing life-sustaining assistance (artificial subsistence or hydration, vitamins), treatments to minimize pain, delays in breathing, or bleeding (including inner bleeding)—treatment that provides comfortable death conditions.

Terms of the DNR Form Completion

Firstly, talk with the main physician to get all the needed information on the risks and benefits of creating the printable DNR form. Usually, the DNR order is created when doctors consider it useless to prevent death anymore, so it is better to just let the patient pass away. Another case is when the patient, their representatives, or relatives do not want the patient to suffer from further treatment, so they let them decease calmly.

Important to mention that if the patient themselves is not capable of making decisions independently or is paralyzed, the form can and must be created and filled by their representative (close relative, spouse, health care proxy, etc.)

Remember that each legal form must be completed according to the local legislation. In North Carolina, the laws §90-321 and §90-322 provide information on the right to Natural Death, which includes the right to prevent special treatment aimed to bring a person back to life in the cases mentioned above.

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Download your fillable North Carolina DNR form in PDF format.

How to Fill Out the DNR Form

1. Get acquainted with the local DNR Form, download and print it out.

2. When ready to fill out the form, start with the patient’s contact information: write their first and last name, middle initials, date of birth, and the date of the form’s creation.

step 1 to filling out the north carolina dnr form

3. In Section A, check only one box with needed information. If the patient does not have a pulse and does not breathe, choose whether to apply Resuscitation (CPR) or not. In each of the sections below that, there is a field to write special instructions on which treatment to use and how, if one wants to specify it by themselves.

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4. The following Section B specifies which treatment to provide in case of a heart attack. The one completing the form must check only one box, defining whether to imply a full treatment (thus, try to save the patient’s life), avoid intensive care, or just provide comfortable treatment.

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5. Section C specifies the kinds of antibiotics provided to the patient in case of staying alive. One needs to check one box only.

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6. Section D must have two boxes checked (one box per column), which provide the information on the nutrition and fluids given to the patient.

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7. Section E requires information about the agreement of the patient’s relatives or medical agents to complete the form. It is needed to place a tick in the box providing needed information.

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8. The following section is to be filled by the main physician, who should leave their printed name, phone number, and the date of the form’s creation.

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9. In the last section, fill in the patient’s or their representative’s printed name, signature, and relation of the representative to the patient, if applicable.

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10. On the next page, the first section is to be filled with the representative’s and the preparer’s personal information. It includes their names, phone numbers, representative’s relation to the patient, preparer’s title, and the date of the form’s completion.

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11. The last table is to be filled by the medical staff of the facilities within which the patient may move. Each row of the table should be filled in a new place or by a new physician and should provide information on whether the form is voided without the creation of the new one, voided because of the new form’s creation, or there are zero changes provided.

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Published: Oct 18, 2021