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23
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25
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36
PLEASE PRINT LAST NAME
FIRST MIDDLE
MAILING ADDRESS CITY
STATE ZIP
PHONE ( ) -
DATE OF BIRTH / / /
STATE OF OHIO DL/ID CARD # OR SOCIAL SECURITY #
DONOR REGISTRY ENROLLMENT OPTIONS OPTION 1
Upon my death, I make an anatomical gift of my organs, tissues, and eyes for any purpose authorized by law. OPTION 2
Upon my death, I make an anatomical gift of the following organs, tissues, and/or eyes selected below:
All organs, tissues and eyes ORGANS TISSUES
Heart Intestines Eyes/Corneas Veins
Lungs Small Bowel Heart Valves Fascia
Liver (and associated vessels) Bone Skin
Kidneys (and associated vessels) Tendons Nerves
Pancreas/Islet Cells Ligaments
For the following purposes authorized by law:
All purposes Transplantation Therapy Research Education
OPTION 3 Please take me out of the Ohio Donor Registry.
SIGNATURE OF DONOR REGISTRANT X
DATE
39
WL Oliwep Tiimi TruHtyu Uhn DLb Crsy
What YLaws in
Ohio’s Do-Nlimit care reinclude carewrite an ordevent of a cpresence of
The followinissues and coinformation may have a Dissues.
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DNR order Law. The DNbe consisten
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40
DNR/CPR Care: The Facts Ohio first adopted a law concerning DNR orders in 1998. DNR stands for “do not resuscitate.” A person who does not wish to have cardiopulmonary resuscitation (CPR) performed may make this wish known through a physician’s order called a DNR order. A DNR order addresses the various methods used to revive people whose hearts have stopped functioning or who have stopped breathing. Cardiopulmonary Resuscitation (CPR) has a broad meaning. It includes any or all of the following:
Administration of chest compressions; Insertion of an artificial airway; Administration of resuscitation drugs; Defibrillation or cardioversion; Provision of respiratory assistance; Initiation of a resuscitative intravenous line; or Initiation of cardiac monitoring.
CPR can be life-saving but some people may not want it administered in certain cases. In some cases, CPR saves lives. In many cases, it is not effective. Many people overestimate the success of CPR. A person who is revived may be left with permanent or painful injury. Resuscitation also may include other treatment, such as drugs, tubes and electric shock. People with terminal illnesses or other serious medical conditions may prefer to focus on comfort care at the end of life rather than receiving CPR when the time comes. For more information about the pros and cons of CPR and whether it is right for you, ask your physician. It is easy to make your wishes about CPR known. If you want to receive CPR when appropriate, you do not need to do anything. Health care providers are required to perform CPR when necessary. If you do not want CPR, you need to discuss your wishes with your physician and ask your physician to write a DNR Order. If your physician agrees that you should not get CPR, he or she can fill out the required form to make your wishes known in case of an emergency. There are different DNR orders that you can choose and discuss with your physician. Under Ohio’s DNR Law, the Ohio Department of Health has established a standardized DNR form. When completed by a physician (certified nurse practitioner or advance practice nurse, as appropriate), these standardized DNR orders allow patients to choose the extent of the treatment they wish to receive or not receive at the end of life. Your physician can further explain the differences in DNR orders. Even if you are healthy now, you may want to state that you do not want to receive CPR if you ever become terminally ill. Ohio has a standard Living Will Declaration form. This form specifically allows you to direct your physician not to administer life-sustaining treatments, including CPR, and to issue a DNR Order if two physicians have agreed that you are either terminally ill or permanently unconscious.
41
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42
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When choic… there is hall want to bown decisiolives. Whenexperience fcan feel as iHospice helpdecisions, topositive cho
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43
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