ARKANSAS OUT-OF-HOSPITAL
DO NOT RESUSCITATE (DNR) DIRECTIVE
(“Directive”)
TABLE OF CONTENTS
- Document Header
- Definitions
- Operative Provisions
- Representations & Warranties
- Covenants & Restrictions
- Revocation, Default & Remedies
- Risk Allocation
- Dispute Resolution
- General Provisions
- Execution Block
1. DOCUMENT HEADER
This Arkansas Out-of-Hospital Do Not Resuscitate Directive (“Directive”) is made effective as of [EFFECTIVE DATE] (the “Effective Date”) by and among:
• Patient: [PATIENT FULL LEGAL NAME], DOB [DATE OF BIRTH] (the “Patient”);
• Authorized Health-Care Provider(s): Any physician, nurse, hospital, nursing facility, hospice, or other health-care provider licensed in the State of Arkansas who, in good-faith reliance on this Directive, withholds or withdraws resuscitative measures (collectively, “Providers”); and
• Emergency Medical Services Personnel: Any individual or entity licensed or certified to provide emergency medical services under Arkansas law (“EMS Personnel”).
Recitals
A. Arkansas law permits a competent adult, or such adult’s authorized surrogate, to refuse cardiopulmonary resuscitation (“CPR”) by executing a valid do-not-resuscitate order.
B. The Patient desires to execute this Directive in accordance with Arkansas requirements for out-of-hospital DNR orders, including EMS recognition.
C. Providers and EMS Personnel require clear legal authority and liability protection when relying on a patient’s expressed wish not to receive CPR.
For adequate consideration, the receipt and sufficiency of which are acknowledged, the Parties agree as follows.
2. DEFINITIONS
“Cardiopulmonary Resuscitation” or “CPR” means chest compressions, defibrillation, artificial ventilation, administration of cardiac drugs, or other life-sustaining procedures intended to restart or support breathing or heartbeat.
“DNR Identifier” means the original, unaltered copy of this Directive (preferably printed on [EMS DIRECTIVE COLOR] paper or otherwise visibly marked) or any device or bracelet approved under Arkansas regulations evidencing a valid DNR order.
“Good-Faith Reliance” means reliance that is honest in fact and made without gross negligence, willful misconduct, or malicious intent.
“Surrogate” means a health-care proxy, agent under a power of attorney for health care, court-appointed guardian, or other legally authorized decision-maker acting for the Patient.
3. OPERATIVE PROVISIONS
3.1 Directive Against Resuscitation
The Patient hereby directs that no cardiopulmonary resuscitation be attempted in the event the Patient experiences cardiac or respiratory arrest after the Effective Date. Providers and EMS Personnel shall allow the Patient to die naturally and shall not initiate or continue CPR.
3.2 Scope of Care Not Otherwise Limited
Except as to CPR, the Patient does not refuse other medical or palliative care. Providers shall render comfort care, pain relief, and other medically indicated treatments consistent with this Directive and applicable law.
3.3 Conditions Precedent
This Directive becomes operative only when both:
a. The Patient is found pulseless, apneic, or in cardiopulmonary arrest; and
b. Providers or EMS Personnel are presented with, or reasonably identify, a valid DNR Identifier.
3.4 EMS Recognition
EMS Personnel shall honor this Directive in any out-of-hospital setting when:
• The Directive bears original (wet-ink) or properly authenticated electronic signatures;
• The Patient, Surrogate, or attending facility provides the Directive or an endorsed copy; and
• The Directive reasonably appears unrevoked and unaltered.
[// GUIDANCE: Arkansas EMS protocols generally require the DNR form to be printed on brightly-colored paper (commonly orange) for rapid field identification.]
3.5 Documentation Requirement
Providers shall document recognition of this Directive in the Patient’s medical record and, where feasible, affix a copy in a prominent location within the chart.
4. REPRESENTATIONS & WARRANTIES
4.1 Patient Representations
a. Capacity. The Patient affirms having decision-making capacity on the Effective Date.
b. Voluntariness. Execution of this Directive is free from undue influence or duress.
c. Understanding. The Patient has had the opportunity to ask questions of the attending physician and understands the medical consequences of refusing CPR.
4.2 Physician Representation
The undersigned physician (“Physician”) certifies:
a. The Patient (or Surrogate) appeared to possess decision-making capacity, or the Surrogate has lawful authority to act.
b. The medical implications of a DNR order were explained in understandable terms.
c. Execution complies with all Arkansas statutory and regulatory requirements then in effect.
4.3 Survival
All representations and warranties survive execution and remain effective unless and until this Directive is revoked pursuant to Section 6.
5. COVENANTS & RESTRICTIONS
5.1 Patient/Surrogate Covenants
a. To provide copies of this Directive to treating facilities and caregivers.
b. To notify Providers promptly if the Patient revokes or alters this Directive.
5.2 Provider Covenants
To honor this Directive in accordance with applicable Arkansas law and accepted medical standards, subject to Section 6 (Revocation) and Section 7 (Risk Allocation).
6. REVOCATION, DEFAULT & REMEDIES
6.1 Revocation by Patient
The Patient (or Surrogate, if the Patient lacks capacity) may revoke this Directive at any time by:
a. A written, signed, and dated revocation;
b. Physically destroying the Directive and all copies; or
c. Verbally expressing intent to revoke in the presence of two adults, at least one of whom is a Provider.
6.2 Effect of Revocation
Upon reasonable notice of revocation, Providers and EMS Personnel shall regard this Directive as void and resume full resuscitative efforts absent a superseding, valid order.
6.3 Default
Failure of Providers or EMS Personnel to honor this Directive after proper presentation constitutes a default under this Section. Available remedies include injunctive or declaratory relief. Monetary damages are limited by Section 7.2.
7. RISK ALLOCATION
7.1 Provider Protection & Indemnification
The Patient agrees to release, defend, and indemnify Providers and EMS Personnel from any civil liability arising out of Good-Faith Reliance on this Directive, to the fullest extent permitted under Arkansas law.
7.2 Limitation of Liability
No Party shall be liable for consequential, incidental, punitive, or exemplary damages for acts or omissions undertaken in Good-Faith Reliance on this Directive.
7.3 Insurance
Nothing herein requires the Patient, Providers, or EMS Personnel to obtain additional insurance; however, existing professional liability coverage shall apply in the ordinary course.
8. DISPUTE RESOLUTION
8.1 Governing Law
This Directive is governed by the health-care laws of the State of Arkansas, without regard to conflict-of-laws principles.
8.2 Injunctive Relief
Because the subject matter involves fundamental bodily integrity, monetary damages are inadequate. A court of competent jurisdiction sitting in Arkansas may grant injunctive or declaratory relief to enforce or clarify this Directive.
8.3 Arbitration, Jury Trial, Forum Selection
Not applicable or required under the Parties’ agreement or Arkansas DNR statutes.
9. GENERAL PROVISIONS
9.1 Amendment
Only a written instrument executed with the same formalities as this Directive may amend it.
9.2 Assignment
Rights and duties under this Directive are personal to the Patient and may not be assigned.
9.3 Severability
If any provision is held invalid, the remaining provisions remain enforceable to the maximum extent permitted.
9.4 Entire Agreement
This Directive constitutes the complete expression of the Patient’s wishes regarding CPR and supersedes all prior inconsistent statements.
9.5 Electronic & Counterpart Signatures
Facsimile, scanned, or digitally-signed counterparts are as effective as originals.
10. EXECUTION BLOCK
[// GUIDANCE: Arkansas requires either TWO adult witnesses or acknowledgement before a notary public. Witnesses must be at least 18, not related to the Patient by blood, marriage, or adoption, not entitled to any portion of the Patient’s estate, and not directly involved in the Patient’s medical care.]
10.1 Patient (or Surrogate) Authorization
I, [PATIENT OR SURROGATE NAME], have read and understand this Directive and voluntarily execute it on the date indicated.
| Signature | Date | Relationship (if other than Patient) |
|---|---|---|
10.2 Physician Confirmation
| Physician Name | AR License # | Signature | Date |
|---|---|---|---|
10.3 Witness Attestation (complete only if not notarized)
We declare that the Patient (or Surrogate) signed or acknowledged this Directive in our presence and appears to be of sound mind and acting voluntarily.
| Witness # | Name | Address | Signature | Date |
|---|---|---|---|---|
| 1 | ||||
| 2 |
10.4 Notary Acknowledgement (optional alternative to Section 10.3)
State of Arkansas )
County of __ )
On this _ day of _, 20__, before me, [NOTARY NAME], a Notary Public, personally appeared [PATIENT OR SURROGATE NAME], known to me (or satisfactorily proven) to be the person whose name is subscribed to this Directive and acknowledged that he/she executed the same for the purposes therein contained.
(Notary Seal)
Notary Public
My Commission Expires: _____
[// GUIDANCE:
1. File originals with the Patient’s primary care provider, hospital, nursing facility, and hospice (if any).
2. Provide a copy to family members and caregivers.
3. Consider placing a DNR bracelet or necklace on the Patient for rapid EMS identification.
4. Review annually or upon any major change in health status.
]