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other than an acute care hospital or a health facility, cardiopulmonary resuscitation procedures be withheld or withdrawn and that I be permitted to die naturally.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 the me (declarant) and all witnesses.
I understand the full import of this declaration.