Medical Directive - DNR

COLORADO CPR DIRECTIVE PREPARATION WORKSHEET

Not a Physician DNR Order

CRITICAL NOTICE: Colorado distinguishes a CPR Directive—an advance directive about CPR—from a DNR, which 6 CCR 1015-2 defines as a physician order to refrain from CPR. This worksheet helps prepare a CPR Directive but is not itself a physician DNR order.

Colorado does not require exclusive use of one specific CPR-directive form. A directive must be apparent and immediately available to EMS providers to serve as lawful authority to withhold or discontinue CPR.

1. INDIVIDUAL INFORMATION

2. DECLARANT AND AUTHORITY

Declarant: ☐ Individual with decision-making capacity ☐ Authorized agent

If an authorized agent signs, identify the authority:

☐ Court-appointed guardian

☐ Agent with health-care decision-making authority under a power of attorney

☐ Proxy decision-maker selected under C.R.S. § 15-18.5-103

☐ Other authority recognized by Colorado or another state's law: [____________________]

Agent name: [________________________________]

Authority document and date: [________________________________]

Medical-record location: [________________________________]

For a minor, confirm that a physician has first issued a DNR order and that the person executing the CPR Directive is authorized under C.R.S. § 15-18.6-102.

3. CPR INSTRUCTION AND INFORMED DISCUSSION

The declarant directs that, if the individual experiences cardiac or respiratory arrest or malfunction:

☐ Do not attempt cardiopulmonary resuscitation.

Under 6 CCR 1015-2, CPR includes artificial ventilation, chest compression, electric shock, airway tubes, and other basic and advanced resuscitative therapies.

The declarant understands that a CPR Directive does not prevent EMS evaluation or appropriate and available palliative services, treatment, and measures.

Questions, values, or treatment preferences:

[____________________________________________________________]

[____________________________________________________________]

Do not use a CPR Directive to add unrelated treatment refusals for antibiotics, artificial nutrition, hydration, or other care. Address broader treatment preferences in the appropriate separate advance directive or medical order.

4. ATTENDING PHYSICIAN CONSULTATION

Attending physician name: [________________________________]

Profession: ☐ M.D. ☐ D.O.

Colorado license number: [________________________________]

Address: [________________________________]

Telephone: [________________________________]

Consultation date: [__/__/____]

☐ The expected consequences of withholding CPR were discussed with the individual or authorized agent.

☐ The declarant's instruction reflects informed refusal of CPR.

Physician signature: [________________________________] Date: [__/__/____]

For a CPR Directive executed under 6 CCR 1015-2, “attending physician” means the consulted licensed M.D. or D.O. Do not substitute an advanced practice nurse for the attending-physician signature required by the rule.

5. TISSUE-DONATION STATEMENT

6 CCR 1015-2 requires a written statement and signature or signatures indicating a decision about tissue donation at death, consistent with Colorado's Revised Uniform Anatomical Gift Act.

☐ I have made a separate anatomical-gift decision and attached or identified it here: [____________________]

☐ I have not made an anatomical gift through this CPR Directive.

Declarant signature for tissue-donation statement: [________________________________]

Date: [__/__/____]

Additional required signature, if applicable: [________________________________]

6. DECLARANT SIGNATURE OR MARK

I direct that CPR not be administered as stated above. I have been informed of the expected consequences of withholding CPR.

Declarant signature or mark: [________________________________]

Printed name: [________________________________]

Capacity: ☐ Individual ☐ Authorized agent

Date: [__/__/____]

The current EMS rule lists the declarant's signature or mark, date, attending-physician information and signature, and tissue-donation statement among the directive's required information. It does not require a witness or notary for the CPR Directive. Do not import witness, notary, electronic-signature, or counterpart terms from unrelated documents.

7. EMS AVAILABILITY AND REPRODUCTIONS

Under 6 CCR 1015-2:

• any CPR Directive that is apparent and immediately available and directs that resuscitation not be attempted is lawful authority to withhold or discontinue CPR;
• EMS providers must obtain reasonable assurance that the directive applies to the individual;
• a photocopied, scanned, faxed, or otherwise reproduced valid directive must be honored;
• a CPR Directive bracelet or necklace may be regarded as valid; and
• in the absence of a CPR Directive, consent to CPR is presumed, although the rule does not require EMS to initiate CPR in every circumstance.

Checklist:

☐ Directive placed where EMS providers can find it immediately

☐ Reproduced copy checked for completeness and legibility

☐ Bracelet or necklace, if used, accurately communicates the CPR instruction

☐ Family, caregivers, hospice, and facilities told where the directive is kept

☐ Local medical direction and prehospital protocol reviewed

8. REVOCATION

6 CCR 1015-2 provides that:

• the individual who is the subject of the directive may revoke it at any time;
• an authorized agent may revoke only a CPR Directive that was originally executed by a guardian, agent, or proxy decision-maker; and
• family members or bystanders who are not the declarant or authorized agent may not revoke it.

Do not use this worksheet as the revocation itself. Communicate the revocation immediately, update the medical record and statewide electronic system if applicable, and remove or replace all active copies and identification.

Date change requested: [__/__/____]

Person notified: [________________________________]

Action taken and record location:

[____________________________________________________________]

9. GOOD-FAITH COMPLIANCE

Under C.R.S. § 15-18.6-104 and 6 CCR 1015-2, an EMS provider who in good faith complies with a CPR Directive is not subject to civil or criminal liability or regulatory sanction for that compliance. The rule also addresses good-faith reliance on directives accessed through the statewide electronic system.

Do not replace the statutory standard with indemnity, release, liability-cap, default, force-majeure, attorneys' fees, forum-selection, or private-remedies clauses.

10. OFFICIAL SOURCES

• Colorado Secretary of State, 6 CCR 1015-2 — https://www.sos.state.co.us/CCR/GenerateRulePdf.do?ruleVersionId=8401&fileName=6%20CCR%201015-2
• Colorado Department of Public Health and Environment, EMS rules — https://cdphe.colorado.gov/emergency-care/engage-with-us/emts-rules-and-regulations
• Colorado General Assembly, C.R.S. Title 15 — https://leg.colorado.gov/agencies/office-legislative-legal-services/colorado-revised-statutes

Verify the current statutes, EMS rule, attending-physician requirements, statewide electronic system, and local protocol before relying on a CPR Directive.