ALASKA DO NOT RESUSCITATE (DNR) MEDICAL DIRECTIVE

(Conforming to Alaska Health-Care Decisions Act and EMS Recognition Requirements)

TABLE OF CONTENTS

I. Document Header
II. Definitions
III. Operative Provisions
IV. Representations & Warranties
V. Covenants & Restrictions
VI. Default & Remedies
VII. Risk Allocation
VIII. Dispute Resolution
IX. General Provisions
X. Execution Block

I. DOCUMENT HEADER

1. Title – Alaska Do Not Resuscitate (DNR) Medical Directive (the “Directive”).
2. Parties –
   a. Principal: [FULL LEGAL NAME OF PATIENT], DOB [MM/DD/YYYY], (“Principal”).
   b. Physician/Qualified Practitioner: [FULL LEGAL NAME], Alaska License No. [LICENSE #] (“Physician”).
3. Recitals –
   a. Principal desires to refuse resuscitative measures in the event of cardiopulmonary arrest.
   b. Physician attests that Principal is competent, duly informed, and executing this Directive voluntarily.
4. Effective Date – This Directive is effective on the latest signature date in Section X unless earlier revoked pursuant to § IX.2.
5. Governing Law – This Directive is governed by Alaska law, including AS § 13.52.010 et seq. and all applicable EMS regulations (collectively, “State Health-Care Law”).

[// GUIDANCE: Insert file or document reference number here to facilitate hospital EMR indexing.]

II. DEFINITIONS

For ease of reference, capitalized terms are defined alphabetically:

“Advance Health-Care Directive” – Any written instruction recognized under State Health-Care Law governing health-care decisions, including this Directive.

“Comfort-One Identification” – An Alaska-approved, state-issued DNR bracelet, necklace, wallet card, or other authorized form of EMS-recognizable identification.

“EMS Personnel” – Emergency medical services personnel licensed or certified under Alaska law, including but not limited to paramedics, EMT-I/II/III, mobile intensive-care paramedics, and first responders.

“Good Faith Reliance” – The observance of and reliance upon this Directive by a health-care provider or EMS Personnel in a manner that a reasonably prudent provider would exercise under similar circumstances.

“Resuscitative Measures” – Cardiopulmonary resuscitation (CPR), chest compressions, defibrillation, advanced airway management, artificial ventilation, and administration of cardiac resuscitative medications in response to cardiopulmonary arrest.

“Revocation” – A legally effective cancellation of this Directive under § IX.2.

III. OPERATIVE PROVISIONS

1. Directive to Withhold Resuscitation
   a. Principal directs all health-care providers and EMS Personnel to withhold Resuscitative Measures in the event of cardiopulmonary arrest.
   b. Palliative or comfort care shall continue unless separately refused.

2. Scope of Treatment
   a. This Directive applies in all settings, including home, hospital, long-term-care, transport, and public locations within Alaska.
   b. The Directive does not prohibit treatment that is not primarily intended to restart the heart or breathing (e.g., pain medication, oxygen for comfort, bleeding control).

3. Portability & Recognition
   a. Upon presentation of this Directive or Comfort-One Identification, EMS Personnel shall honor the Principal’s refusal of Resuscitative Measures.
   b. If transported out of state, providers should make reasonable efforts to determine recognition under the receiving jurisdiction’s laws.

4. Documentation & Filing
   a. Physician shall place a copy in the Principal’s medical record within [__] business days.
   b. Principal or Agent should maintain a readily accessible copy on-person and at the Principal’s residence.

5. Emergency Contact & Health-Care Agent Information
   • Primary Agent: [NAME, PHONE, EMAIL]
   • Alternate Agent: [NAME, PHONE, EMAIL]

[// GUIDANCE: Consider inserting QR code linking to digital copy for EMS quick access.]

IV. REPRESENTATIONS & WARRANTIES

1. Principal Representations
   a. Principal is at least eighteen (18) years of age or an emancipated minor.
   b. Principal is of sound mind, acting voluntarily, and fully understands the nature and consequences of this Directive.

2. Physician Certifications
   a. Physician has discussed Resuscitative Measures, alternatives, and foreseeable outcomes with Principal.
   b. Physician reasonably believes Principal possesses decision-making capacity at the time of execution.

3. Survival – The representations in this Section survive execution and remain effective unless revoked.

V. COVENANTS & RESTRICTIONS

1. Principal Covenants
   a. To display Comfort-One Identification when reasonably possible.
   b. To promptly inform the Physician of any change in health status that might affect this Directive.

2. Physician Covenants
   a. To update or re-execute this Directive if materially altered.
   b. To supply copies to facilities and agents as requested.

3. Restrictions on Alteration – No handwritten or partial modifications shall be effective unless executed with the same formalities as this Directive.

VI. DEFAULT & REMEDIES

1. Failure to Honor Directive – Any provider who disregards this Directive, absent good-faith uncertainty of validity, may be subject to:
   a. Professional discipline under applicable licensing boards; and
   b. Civil liability for interference with Principal’s rights.

2. Notice & Cure – A provider who questions validity shall, if time permits, immediately consult the Physician or Agent.

3. Injunctive Relief – Principal or Agent may seek temporary, preliminary, or permanent injunctions to enforce this Directive.

VII. RISK ALLOCATION

1. Indemnification (Provider Protection) – Principal and his/her estate release and hold harmless all providers and EMS Personnel who, in Good Faith Reliance, withhold Resuscitative Measures pursuant to this Directive.

2. Limitation of Liability – No provider or EMS Personnel acting in good faith shall be liable for damages beyond the good-faith standard established by State Health-Care Law.

3. Insurance – Nothing herein requires a provider to maintain additional insurance coverage, but providers must maintain any coverage mandated by professional regulations.

4. Force Majeure – Providers are excused from compliance when prevented by circumstances beyond their reasonable control (e.g., mass-casualty event preventing verification of Directive).

VIII. DISPUTE RESOLUTION

1. Governing Law – This Directive shall be construed in accordance with the laws of the State of Alaska.
2. Forum Selection – Any action to enforce or interpret this Directive shall be brought in a court of competent jurisdiction in the State of Alaska.
3. Arbitration / Jury Waiver – Not applicable.
4. Injunctive Relief – See § VI.3.

IX. GENERAL PROVISIONS

1. Amendment – Principal may amend this Directive only by executing a new document meeting all statutory formalities.
2. Revocation – This Directive may be revoked at any time by:
   a. Oral or written statement by Principal to any provider or EMS Personnel;
   b. Physical destruction of the Directive or Comfort-One Identification by Principal or at Principal’s direction; or
   c. Execution of a later-dated Advance Health-Care Directive expressly revoking this Directive.
3. Assignment – Rights and obligations herein are personal to Principal and may not be assigned.
4. Severability – If any provision is held unenforceable, remaining provisions remain in effect to the fullest extent permitted by law.
5. Integration – This Directive constitutes the entire DNR instruction of Principal and supersedes all prior inconsistent directives regarding Resuscitative Measures.
6. Electronic Signatures – Permitted if compliant with Alaska’s Uniform Electronic Transactions Act.
7. Counterparts – This Directive may be executed in multiple counterparts, each deemed an original.

X. EXECUTION BLOCK

A. Principal Signature

I, the undersigned Principal, declare that I am fully informed and voluntarily execute this Directive.

B. Physician / Qualified Practitioner Attestation

I attest that the Principal appears to have decision-making capacity and that the foregoing Directive reflects the Principal’s stated wishes.

Print Name: _____
Business Address: ______
Phone: __________

C. Witnesses (select one of the two options below to satisfy Alaska requirements)

Option 1 – Two Adult Witnesses (Not Health-Care Providers)
We declare that the Principal signed or acknowledged this Directive in our presence and appears to be of sound mind and acting voluntarily.
| Witness #1 Signature | Date | Witness #2 Signature | Date |
|----------------------|------|----------------------|------|
| ____ | | ____ | |
Print Name: ____ Print Name: ____
Address: ____ Address: ____

Option 2 – Notary Public

State of Alaska )
) ss.
Judicial District )

On this _ day of __, 20_, before me, the undersigned notary public, personally appeared ______, proved to me on the basis of satisfactory evidence to be the person whose name is subscribed above, and acknowledged executing the same voluntarily for the purposes stated therein.

Notary Public Signature: ______
My Commission Expires: _______

[// GUIDANCE: Advise client to file the executed Directive with primary care provider, hospital, and State electronic registry (if available). Always verify current Alaska EMS DNR regulations prior to finalization.]