State Codes and Statutes
Statutes > Kansas > Chapter65 > Article49 > Statutes_2696565-4942
65-4942. Same; form.A "do not resuscitate" directive shall be in substantially thefollowing form:
An advanced request to Limit the Scope ofEmergency Medical Care
I, ____________________, request limited emergency care as herein (name)described.
I understand DNR means that if my heart stops beating or if I stop breathing,no medical procedure to restart breathing or heart functioning will beinstituted. I understand this decision will not prevent me from obtaining otheremergency medical care by pre-hospital care providers or medical care directedby a physician prior to my death. I understand I may revoke this directive at any time. I give permission for this information to be given to the pre-hospital careproviders, doctors, nurses or other health care personnel as necessary toimplementthis directive. I hereby agree to the "Do Not Resuscitate" (DNR) directive. I AFFIRM THIS DIRECTIVE IS THE EXPRESSED WISH OF THE PATIENT, IS MEDICALLYAPPROPRIATE, AND IS DOCUMENTED IN THE PATIENT'S PERMANENT MEDICAL RECORD. In the event of an acute cardiac or respiratory arrest, no cardiopulmonaryresuscitation will be initiated. *Signature of physician not required if the above-named is a member of a churchor religion which, in lieu of medical care and treatment, provides treatment byspiritual means through prayer alone and care consistent therewith inaccordance with the tenets and practices of such church or religion. I hereby revoke the above declaration. History: L. 1994, ch. 143, § 2; April 14.
____________________________________ _________________________ Signature Date
____________________________________ _________________________ Witness Date_________________________________ _____________________________Attending Physician's Signature* Date
_________________________________ _____________________________ Address Facility or Agency Name________________________________ ____________________________ Signature Date
