Attorney-Approved Do Not Resuscitate Order Template for Mississippi

This Mississippi Do Not Resuscitate (DNR) Order is designed to provide individuals with the means to communicate their wishes regarding resuscitation efforts in cases of cardiac or respiratory arrest. Completing this document reflects your decision not to have Cardiopulmonary Resuscitation (CPR) performed on you. This document complies with relevant Mississippi laws specifically related to DNR orders. It's important to discuss this decision with your healthcare provider and loved ones to ensure your wishes are clearly understood and respected.

Patient Information:

• Full Name: ___________________________
• Date of Birth: ________________________
• Address: ______________________________
• City: _______________ State: Mississippi Zip: _________
• Phone: _______________________________

Medical Provider Information:

• Physician's Name: ______________________
• Physician's Phone: ____________________
• Facility Name (If applicable): ____________
• Facility Address: ______________________

DNR Order Statement:

I, _________________, understand the full implications of this decision and voluntarily request that no resuscitative measures, including CPR, be initiated. I understand that this order does not affect the provision of other emergency care, including oxygen, pain relief, and comfort measures.

Signature:

• Patient's Signature: _________________________ Date: ____________
• If patient is unable to sign, Healthcare Proxy or Legal Guardian: ____________________________________ Date: ____________
• Physician's Signature: _______________________ Date: ____________ Physician's License Number: __________

Witness Information:

• Witness 1 Signature: _____________________ Date: ____________
• Witness 2 Signature: _____________________ Date: ____________

Instructions:

1. Review the information provided carefully to ensure accuracy.
2. Discuss the DNR order with a healthcare provider to clearly understand its implications.
3. Ensure the document is signed by the required parties, including the patient, a legal representative if the patient is unable, and the attending physician.
4. Keep the original document in an easily accessible location, and provide copies to relevant family members, healthcare proxies, and medical providers.

The undertaking of a DNR order is a significant and personal decision requiring thoughtful consideration and discussion with healthcare professionals and loved ones. This document, once completed and properly executed, will serve to communicate your healthcare wishes in respect to resuscitative measures.