Indiana Code Title 16. Health § 16-36-5-15

Sec. 15. An out of hospital DNR declaration and order must be in substantially the following form:

OUT OF HOSPITAL DO NOT RESUSCITATE DECLARATION AND ORDER

This declaration and order is effective on the date of execution and remains in effect until the death of the declarant or revocation.

OUT OF HOSPITAL DO NOT RESUSCITATE DECLARATION

Declaration made this ___ day of __________.  I, __________, being of sound mind and at least eighteen (18) years of age, willfully and voluntarily make known my desires that my dying shall not be artificially prolonged under the circumstances set forth below.  I declare:

My attending physician, advanced practice registered nurse, or physician assistant has certified that I am a qualified person, meaning that I have a terminal condition or a medical condition such that, if I suffer cardiac or pulmonary failure, resuscitation would be unsuccessful or within a short period I would experience repeated cardiac or pulmonary failure resulting in death.

I direct that, if I experience cardiac or pulmonary failure in a location other than an acute care hospital or a health facility, cardiopulmonary resuscitation procedures be withheld or withdrawn and that I be permitted to die naturally.  My medical care may include any medical procedure necessary to provide me with comfort care or to alleviate pain.

I understand that I may revoke this out of hospital DNR declaration at any time by a signed and dated writing, by destroying or canceling this document, or by communicating to health care providers at the scene the desire to revoke this declaration.

This declaration was signed by me and by the witnesses in compliance with Indiana law and by:  [Initial or check only one (1) of the following spaces]

___ Signing on paper or electronically in each other's direct physical presence.

___ Signing in separate counterparts on paper using two (2) way, real time audiovisual technology.

___ Signing electronically using two (2) way, real time audiovisual technology or telephonic interaction.

___ Signing in separate counterparts on paper using telephonic interaction between me (the declarant) and all witnesses.

I understand the full import of this declaration.

IF THE DECLARANT IS INCAPACITATED OR INCOMPETENT, the adult who signed above for the declarant is the:  [Initial or check only one (1) of the following spaces]

___ Court appointed guardian of the declarant's person.

___ Agent or attorney in fact (POA) under the declarant's health care power of attorney.

___ Health care representative for the declarant under a written advance directive or other written appointment.

___ Proxy for the declarant (state relationship to declarant)

________________________________________

Address and other optional contact information for guardian, agent, representative, or proxy who signed for the declarant:

_________________________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________________________

The declarant is personally known to me, and I believe the declarant to be of sound mind.  I did not sign the declarant's signature above, for, or at the direction of, the declarant.  I am not a parent, spouse, or child of the declarant.  I am not entitled to any part of the declarant's estate or directly financially responsible for the declarant's medical care.  I am competent and at least eighteen (18) years of age.

Witness__________Printed name__________Date__________

Witness__________Printed name__________Date__________

OUT OF HOSPITAL DO NOT RESUSCITATE ORDER

I,__________, the attending physician, advanced practice registered nurse, or physician assistant of __________, have certified the declarant as a qualified person to make an out of hospital DNR declaration, and I order health care providers having actual notice of this out of hospital DNR declaration and order not to initiate or continue cardiopulmonary resuscitation procedures on behalf of the declarant, unless the out of hospital DNR declaration is revoked.

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