Sign this DNR Please

Patient was seen in minor medical area for his chronic low back pain, which shocked us because he is a drug seeking cardiac cripple. Doc deemed him non urgent, business office informed that he need to pay co-pay, or be seen by his primary care doctor, he utilized his extensive vocabulary of profanity. Then he reverted back to his old complaints of chest pain. This is were I was called to handle the problem. Told nurse to get a wheel chair. This is when Mr. dying decided to put on a show. Refused to get into wheel chair and to be taking back to the main ED. Stumbled out of the minor med area screaming that he was dying, stumbling into walls the whole way. Shaking and weaving c/o chest pain and dizziness. fell to floor in the middle of the waiting room screaming at the top of his lungs that we refuse to treat him unless he paid. Told us not to touch him and that we was going to attempt to walk the 30 miles to the better hospital for treatment, if he didn't die prior to getting there. Popping nitro and grabbing his chest while still refusing to have his chest pain evaluated. So, what was my response to all of this. Well being the charge nurse, I had to look out for the liability of what would happen if this patient really did code in the waiting room and we treated him against his wishes. I informed patient that he would not be treated for his back pain without a co-pay, but that we would be more than happy to eval him for his chest pain. Also, because he refused treatment at this time, it would be considered assault and battery if we picked him up off the floor and rushed him back for treatment. Further more, if he was serious regarding no treatment, then would you please sign this DNR, and I handed him the form.