CPR/DNR Consent Form

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CPR/DNR Consent Form

Before your appointment, please complete this form as thoroughly and correctly as you can so that we may get to know you and your pet(s).

Name *

First

Last

Email *

Pet's Name *

You are being presented with this form because your pet is critically ill or injured and the veterinarian fears that your pet may stop breathing (respiratory arrest) or may stop breathing and have no heartbeat (cardiopulmonary arrest.) If this is the case your pet will die unless immediate resuscitation attempts are started. It is best for you to consider this possibility and make decisions before the need arises. This allows you to become fully informed and ask any questions you might have. *

I have read and understand

You are being presented with this form because when your pet arrived at the hospital he/she was not breathing or was not breathing and had no heartbeat. Until you have read and understood this form and have asked any questions you wish answered the staff will be starting CPR in an attempt to revive your pet. If you do not wish CPR to continue please advise a staff member IMMEDIATELY. *

I have read and understand

CPR is the resuscitation of an animal that has stopped breathing or has stopped breathing and whose heart is not beating. Resuscitation of an animal that has stopped breathing but still has a heartbeat is more likely to succeed than resuscitation of an animal with no breathing and no heartbeat. *

I have read and understand

DNR means “do not resuscitate”. This is a decision that CPR is not to be performed in the event that the pet stops breathing or has no heartbeat. If you chose DNR and your pet stops breathing or his/her heart stops beating then we will not attempt to revive your pet and your pet will die. *

I have read and understand

Animals that have survived cardiopulmonary arrest and have been successfully resuscitated (CPR) are extremely critical and unstable. Survival of respiratory arrest in which the heart has continued to beat carries a slightly better prognosis. The likelihood of re-arrest is high and usually occurs within 4 hours of the initial arrest. This means that there is only about a 20 % chance that your pet will stay alive for the first 4 hours after resuscitation. Long term survival is even more grave, and may be as low as 1%. *

I have read and understand

Management of the post-arrest patient requires vigilant monitoring and the technical expertise of dedicated critical care personnel. This care is costly and the outcome is uncertain. *

I have read and understand

Please select one of the following options in the event your pet experiences cardiac or respiratory arrest *

I wish the staff to perform CPR (resuscitation) on my pet if my pet suffers from cardiac or respiratory arrest. My pet may not respond to CPR or may respond initially and then suffer another arrest later. My pet may die despite CPR. The estimate for initial CPRis $300 to $500. The estimate for the first 24 to 48 hours of veterinary care after CPR at a 24 hour care clinic depends partially on pre-existing injury or illness and may be $1500 to $3500. Costs can greatly exceed this estimate.
I DO NOT want CPR performed on my pet. I understand that if my pet stops breathing and/or his/her heart stops beating that my pet will die unless CPR is performed. I elect to have DNR orders placed on my pets record OR I elect that the veterinary staff stop the initial attempts at CPR that may have been started while | was being informed of the condition of my pet and my options.

Signature *

Clear Signature

I HAVE READ AND UNDERSTOOD THE INFORMATION ABOVE OR HAD IT EXPLAINED TO MY SATISFACTION.

Today's Date *

CPR/DNR Consent Form

CPR/DNR Consent Form

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