CALIFORNIA DO-NOT-RESUSCITATE (DNR) DIRECTIVE
(Advance Health Care Directive – Prehospital Do-Not-Resuscitate Order)
[// GUIDANCE: This template is intended to satisfy California’s Prehospital Do-Not-Resuscitate (“DNR”) requirements and the broader Advance Health Care Directive framework under Division 4.7 of the California Probate Code (commencing with § 4600). Customize bracketed items and review all statutory references before final execution.]
TABLE OF CONTENTS
- Document Header
- Definitions
- Operative Provisions
- Representations & Warranties
- Covenants & Restrictions
- Default & Remedies
- Risk Allocation
- Dispute Resolution & Governing Law
- General Provisions
- Execution Block
1. DOCUMENT HEADER
1.1 Title.
CALIFORNIA DO-NOT-RESUSCITATE (DNR) DIRECTIVE
1.2 Parties.
a. “Patient”: [PATIENT FULL LEGAL NAME], an individual currently residing at [ADDRESS].
b. “Agent”: [PRIMARY AGENT NAME], if any, appointed under an Advance Health Care Directive executed contemporaneously or previously.
c. “Physician”: [ATTENDING/PRIMARY PHYSICIAN NAME, M.D./D.O., LICENSE NO.].
1.3 Effective Date.
This Directive becomes effective immediately upon the latest date of signature appearing in the Execution Block and remains in effect until revoked in accordance with Section 9.2.
1.4 Recitals.
WHEREAS, Patient desires, while competent, to make legally-binding instructions regarding the withholding of cardiopulmonary resuscitation (“CPR”) in the event of cardiac or respiratory arrest; and
WHEREAS, California law authorizes individuals to execute a prehospital DNR order recognized by Emergency Medical Services (“EMS”) personnel;
NOW THEREFORE, Patient, intending to be legally bound, issues the following Directive.
2. DEFINITIONS
For purposes of this Directive, capitalized terms have the meanings set forth below:
“Advance Health Care Directive” – A written instrument executed in compliance with Cal. Prob. Code Div. 4.7, authorizing health-care instructions, including appointment of an Agent.
“Agent” – The individual designated by Patient to make health-care decisions pursuant to an Advance Health Care Directive or durable power of attorney for health care.
“Comfort-Care Measures” – Medical or palliative interventions intended solely to alleviate pain or provide comfort, excluding CPR as defined herein.
“CPR” – Cardiopulmonary resuscitation, including chest compressions, defibrillation, artificial ventilation, endotracheal intubation, vasoactive drug administration, and any other advanced cardiac life support (“ACLS”) measures intended to restore circulatory or respiratory function.
“Directive” – This California Do-Not-Resuscitate Directive, together with any attachments or successor instruments.
“EMS Personnel” – Licensed or certified first responders, emergency medical technicians, paramedics, and mobile intensive care nurses acting within an EMS system authorized by California law.
“Physician” – Patient’s currently supervising or attending physician who, by signing this Directive, confirms the medical appropriateness of a DNR order for the Patient.
“Revocation” – A valid oral or written act by Patient (or Authorized Individual under California law) expressly canceling this Directive in whole or in part, effective immediately upon communication to EMS Personnel or other health-care providers.
3. OPERATIVE PROVISIONS
3.1 DNR ORDER. Patient hereby directs that no person shall perform CPR on Patient in the event of cardiac or respiratory arrest. All other indicated medical treatment, including Comfort-Care Measures, hydration, nutrition, pain management, and palliative care, may be provided unless otherwise declined in a separate, duly-executed advance directive or physician order.
3.2 SCOPE OF APPLICATION.
a. Prehospital Care. EMS Personnel presented with an original, legible photocopy, or identification bracelet/medallion referencing this Directive shall withhold CPR and comply with applicable EMS protocols.
b. In-Facility Care. This Directive serves as a physician order within any licensed health-care facility in California once incorporated into the Patient’s medical record pursuant to Section 5.2.
3.3 AUTHORIZED DECISION-MAKERS. If Patient is incapacitated, the following individuals may confirm continued intent to withhold CPR:
i. Agent;
ii. Patient’s legal guardian or conservator;
iii. The applicable surrogate decision-maker hierarchy under Cal. Prob. Code § 4715.
3.4 EMS IDENTIFICATION. Patient may obtain and wear an EMS-approved DNR medallion or bracelet issued by a California EMS Authority-approved vendor. Presentation of such medallion or bracelet shall constitute presumptive evidence of a valid DNR order.
3.5 PORTABILITY. Copies of this Directive, including electronic or faxed versions, shall be deemed originals and honored by EMS Personnel and all California-licensed facilities, subject to verification of authenticity.
4. REPRESENTATIONS & WARRANTIES
4.1 Patient represents that:
a. Patient is at least 18 years of age (or an emancipated minor) and of sound mind at the time of execution;
b. Patient has discussed the implications of a DNR order with the Physician and, where applicable, the Agent and family; and
c. Execution of this Directive is voluntary and free of duress or undue influence.
4.2 Physician represents that:
a. Physician has reviewed Patient’s medical condition and confirms that a prehospital DNR order is medically appropriate;
b. Physician has explained the nature, consequences, and potential alternatives to a DNR order to Patient (and Agent, if present); and
c. Physician will enter a corresponding DNR order in Patient’s medical chart promptly upon execution.
All representations and warranties in this Section 4 survive the revocation or termination of this Directive to the extent necessary to enforce liability protections under Section 7.
5. COVENANTS & RESTRICTIONS
5.1 Patient covenants to:
a. Inform family members, caregivers, and facility staff of the existence of this Directive;
b. Maintain the original Directive in an easily accessible location and provide copies to health-care providers;
c. Wear or carry EMS-approved DNR identification when outside a licensed facility, if possible.
5.2 Physician covenants to:
a. Place a signed copy of this Directive and corresponding DNR order in Patient’s permanent medical record;
b. Review the continuing appropriateness of the DNR order at each significant change in Patient’s health status.
5.3 Agent covenants to:
a. Present this Directive to EMS Personnel and health-care providers when necessary;
b. Act in good faith to honor Patient’s expressed wishes herein.
6. DEFAULT & REMEDIES
6.1 Events of Default.
a. Initiation of CPR contrary to this Directive;
b. Failure of Physician or facility to honor a valid DNR order;
c. Withholding of Comfort-Care Measures in contravention of Section 3.1.
6.2 Cure. Upon notice of an Event of Default, the responsible provider shall, to the extent feasible:
a. Cease resuscitative efforts;
b. Provide Comfort-Care Measures;
c. Document the deviation and corrective actions in the medical record.
6.3 Remedies. Patient (or Agent/estate) shall be entitled to:
a. Immediate injunctive relief to enforce compliance with this Directive; and
b. Recovery of reasonable attorneys’ fees and costs incurred in enforcing the Directive.
[// GUIDANCE: Monetary damages for wrongful resuscitation are rarely awarded; however, injunctive relief language provides a prophylactic enforcement mechanism.]
7. RISK ALLOCATION
7.1 Good-Faith Immunity. No health-care provider, EMS Personnel, or Agent acting in good faith reliance on this Directive shall incur civil or criminal liability or be subject to disciplinary action for honoring or failing to honor this Directive if, after reasonable inquiry, its validity could not be determined.
7.2 Indemnification. Patient agrees to indemnify, defend, and hold harmless all health-care providers, EMS agencies, and their respective personnel (collectively, “Indemnitees”) from any and all claims, liabilities, damages, costs, or expenses (including reasonable attorneys’ fees) arising out of or relating to good-faith compliance with this Directive, except to the extent caused by gross negligence or willful misconduct of the Indemnitee.
7.3 Limitation of Liability. In any action arising from the good-faith implementation or attempted implementation of this Directive, the liability of any Indemnitee shall not exceed the amount recoverable under applicable professional liability insurance, if any.
7.4 Force Majeure. Indemnitees shall not be liable for non-performance or delayed performance of obligations under this Directive caused by circumstances beyond their reasonable control, including mass-casualty incidents or disaster triage protocols that supersede individual directives under applicable law.
8. DISPUTE RESOLUTION & GOVERNING LAW
8.1 Governing Law. This Directive shall be governed by, and construed in accordance with, the laws of the State of California without regard to conflict-of-law principles.
8.2 Forum Selection. Any action to enforce or interpret this Directive shall be brought exclusively in a court of competent jurisdiction located in [COUNTY], California.
8.3 Injunctive Relief. Because monetary damages may be inadequate to protect Patient’s interest in self-determination, equitable relief—including temporary, preliminary, and permanent injunctions—shall be available to enforce Sections 3 and 6 without the necessity of posting bond.
8.4 Jury Waiver. Not applicable.
8.5 Arbitration. Not applicable.
9. GENERAL PROVISIONS
9.1 Amendment. Patient may amend this Directive only by executing a subsequent written instrument that expressly supersedes or modifies the provisions hereof and complies with the execution requirements of Section 10.
9.2 Revocation. Patient (or Authorized Individual under applicable law) may revoke this Directive at any time by:
a. A written, dated, and signed revocation;
b. Oral expression of intent to revoke in the presence of two adult witnesses; or
c. Physically destroying the original Directive.
Revocation is effective immediately upon communication to EMS Personnel or a treating health-care provider.
9.3 Assignment. Rights and obligations under this Directive are personal to the Parties and may not be assigned.
9.4 Severability. If any provision of this Directive is held invalid or unenforceable, the remaining provisions shall remain in full force and effect.
9.5 Integration. This Directive constitutes the entire understanding of the Parties regarding the subject matter hereof and supersedes all prior or contemporaneous oral or written directives concerning CPR.
9.6 Counterparts; Electronic Signatures. This Directive may be executed in multiple counterparts, each of which shall be deemed an original. Signatures transmitted by facsimile, PDF, or other electronic means shall be deemed original signatures for all purposes.
10. EXECUTION BLOCK
[// GUIDANCE: California permits EITHER (i) two adult witnesses OR (ii) notarization. Many facilities also require the physician signature found below for EMS recognition.]
PATIENT
Signature: _____ Date: __
Printed Name: ______ DOB: ____
PRIMARY AGENT (if any)
Signature: _____ Date: __
Printed Name: ______ Relationship: ___
PHYSICIAN
I certify that the above-named Patient has been advised of the medical implications of a Do-Not-Resuscitate order and that, in my clinical judgment, such order is appropriate.
Signature: _____ Date: _
Printed Name: ______ License No.: _
Address / Phone: ___ __
WITNESS #1
I declare under penalty of perjury under the laws of the State of California that I am at least 18 years of age, 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 Patient’s health-care decision-making.
Signature: _____ Date: __
Printed Name: ______
WITNESS #2
Same declaration as Witness #1.
Signature: _____ Date: __
Printed Name: ______
— OR —
NOTARY ACKNOWLEDGMENT
State of California )
County of _ ) On //, before me, ____, a Notary Public, personally appeared _____, who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to this instrument, and acknowledged that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct.
WITNESS my hand and official seal.
Signature: _________ (Seal)
ATTACHMENTS
A. Copy of Patient’s Advance Health Care Directive (if separate)
B. EMS-Approved DNR Bracelet/Medallion Order Form (optional)
[// GUIDANCE: Attachments are not strictly required but strongly recommended for completeness and ease of verification by EMS personnel.]
END OF DOCUMENT