Wisconsin Do Not Resuscitate Order (DNR) Form

The Wisconsin DNR (Do Not Resuscitate) form is a legal document that is used in cases where an individual refuses further medical intervention. Basically, we are talking about cases where resuscitation is necessary due to a failure of the heart or lungs. At the same time, an individual themselves can decide to refuse treatment.

If this DNR form is signed by the patient or recorded in the form of an oral appeal due to the inability to sign, then doctors will be required to familiarize themselves with the patient’s legally attested desire and stop medical procedures, which may include:

  • heart defibrillation
  • cardiac pacing
  • CPR
  • advanced airway management.

According to the law, this form must be signed by the patient and the physician. If the patient is physically unable to sign the document, a legal representative (for example, a relative) should do it for them. All the details described above are specified in local laws §154.17 – §154.29 of the State of Wisconsin.

This form can be provided to the patient only in strictly defined cases:

  • The patient is terminally ill
  • In this physical condition, resuscitation can cause significant harm to the patient, while the possible negative consequences are really dangerous. So, even the opportunity to provide medical assistance is extremely risky
  • In this physical condition of the patient, resuscitation may not help and may not lead to the restoration of breathing and heartbeat

Furthermore, you can make yourself acquainted with the form sample that is accepted in Wisconsin.

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Download your fillable Wisconsin DNR form in PDF format.

How to Fill Out Wisconsin DNR Form

Now let us continue with the process of filling out the Wisconsin DNR form. Below you will find detailed guidelines that will help you figure out what to do in a situation where a patient expresses their will to sign this form.

1. Write Down Your Personal Details

The first thing you as a patient will have to do is fill in your full name, birth date, address, and ZIP code. As has been already mentioned before, a representative has a right to fill out all the data on behalf of the patient.

step 1 to filling out the wisconsin dnr form - write down your personal details

2. Make Yourself Acquainted With the Instructions

Just below the empty lines for personal information, you will find a paragraph that contains several warnings and the consequences of signing this form. The same paragraph is a confirmation of your intentions that should be indicated in the form.

step 2 to filling out the wisconsin dnr form - make yourself acquainted with the instructions

3. Choose a Person to Sign the Form

Further, before signing, the individual filling out this document must choose who exactly they are. In total, the form presents three options for those people who can potentially affix their signature and thereby confirm the patient’s intentions: Patient, Legal Guardian, Health Care Agent.

step 3 to filling out the wisconsin dnr form - choose a person to sign the form

4. Put a Signature and the Date

As the next step, an individual must put their signature as a confirmation of the actions indicated in the form above and record the current date of signing the document.

step 4 to filling out the wisconsin dnr form - put a signature and the date

5. Let the Attending Physician Fill Out and Sign the Form

Then the attending physician who is treating this patient must write down their personal information. They must fill in their name, phone number, append their signature, and record the current date when the document is signed.

step 5 to filling out the wisconsin dnr form - let the attending physician fill out and sign the form

6. Order a Special Bracelet

After filling out and signing the form, the attending physician is obliged to prepare and put on the patient a special plastic or metal bracelet that is a visible confirmation that the patient signed the DNR form and they need a special treatment program. To order a bracelet, you must provide a copy of the signed DNR form and pay for the provided bracelet.

step 6 to filling out the wisconsin dnr form - order a special bracelet

Published: Oct 18, 2021