Do Not Resuscitate-Termination of Life Support Worksheet
5. Doctors recommending termination of life support: (See attached statements) Name Address Phone# Attending Physician: Physician 1: Physician 2: Diagnosis: Prognosis: Efforts to contact Family Members: _____No known family _____Unsuccessful efforts to contact known family members consisted of. the following: _____Known family members notified ................
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