Form No.

Hospital No.:

Case No.:

Room No.:
DO NOT RESUSCITATE (DNR)
WITHHOLD/ WITHDRAW LIFE SUSTAINING TREATMENT ORDER
(This form shall always accompany a DNR/WH/WD written order in the patient’s chart)

PATIENT’S NAME: ________________________________________________ AGE: ___________ SEX: ______________

ATTENDING PHYSICIAN: ________________________________________
DATE: __________________________________________ TIME: ______________________________________AM/PM
PATIENT’S MENTAL CAPACITY: ( ) CAPABLE ( ) INCAPACITATED
In case of cardiopulmonary (CP) arrest: CALL THE CODETEAM ( ) YES ( ) NO
WITHHOLD WITHDRAWN
Resuscitation/ CPR
Defibrillation
Endotracheal Intubation
Mechanical Ventilation
Artificial Hydration/ Nutrition
Medications
Dialysis
Others
1.
2.
Treatment to be withheld/ withdrawn (Check all that apply):

RATIONALE (Check all that apply)

( ) Terminally ill
( ) Immediately Dying
( ) Chronic Coma
( ) Patient (or relative/ legal surrogate) determination that burdens outweigh benefits.
( ) Prior Legal directive/ arrangement
( ) Others _____________________________________________________________________________________

Other Instructions/ Specific Orders:

____________________________________________________________________________________________________________
________________________________________________________________________________________

I have discussed that the above request with patient/ family member/ legal representative named below understands and consents
to the withholding/ withdrawal of treatment indicated above.

_____________________________ _______________ __________________________ _______________

Signature over Printed Name Relationship Signature over Printed Name Relationship

_____________________________ _______________ __________________________ _______________

Signature over Printed Name Relationship Signature over Printed Name Relationship

____________________________________
Physician’s Signature over Printed Name
Witnesses:
_____________________________ __________________________
Signature over Printed Name Signature over Printed Name