CONNECTICUT OUT-OF-HOSPITAL

DO NOT RESUSCITATE (“DNR”) MEDICAL DIRECTIVE
[MODEL FORM]

[// GUIDANCE: This template is drafted to comply with current Connecticut Department of Public Health (“DPH”) requirements for out-of-hospital DNR/MOLST recognition, the Connecticut Health Care Decisions Act, and generally accepted EMS protocols. Customize bracketed fields, review against the most current DPH form instructions, and obtain medical‐legal review before use.]

TABLE OF CONTENTS

1. Document Header
2. Definitions
3. Operative Provisions
4. Representations & Warranties
5. Risk Allocation
6. General Provisions
7. Execution Block
8. Revocation/Modification Record

1. DOCUMENT HEADER

1.1 Title
 Connecticut Out-of-Hospital Do Not Resuscitate Medical Directive (the “Directive”).

1.2 Parties
a. Declarant: [PATIENT FULL LEGAL NAME], residing at [ADDRESS] (“Declarant”).
b. Authorizing Clinician: [PHYSICIAN/APRN/PA FULL LEGAL NAME], licensed in Connecticut under license no. [LICENSE #] (the “Authorizing Clinician”).
c. Recognized Providers: All Emergency Medical Services (“EMS”) personnel, hospitals, nursing facilities, hospice programs, and other health-care providers that may treat Declarant (collectively, “Providers”).

1.3 Recitals
A. Declarant possesses decision-making capacity and desires to direct that no cardiopulmonary resuscitation (“CPR”) or advanced cardiac life support be attempted in the event of cardiopulmonary arrest.
B. Connecticut law permits competent adults to execute out-of-hospital DNR orders recognized by EMS when properly executed and witnessed.
C. Authorizing Clinician, after consultation with Declarant (or Declarant’s legally authorized representative), concurs with this Directive.
D. The parties enter into this Directive effective as of [EFFECTIVE DATE] (the “Effective Date”) under the laws of the State of Connecticut.

2. DEFINITIONS

“Cardiopulmonary Arrest” means the absence of a palpable pulse and spontaneous respirations.
“CPR” means chest compressions, defibrillation, advanced airway management, artificial ventilation, administration of cardiac medications, or any combination thereof.
“EMS Recognition Materials” means the original fully executed Directive, the state-approved wallet card, and/or an approved DNR bracelet/necklace issued pursuant to DPH guidelines.
“Good Faith” means an honest belief, without malice or intent to defraud, that the Directive is valid and applicable.
“Revocation” has the meaning set forth in Section 3.6.
“Scope of Treatment Order” refers to any accompanying MOLST or POLST form addressing additional interventions beyond resuscitation.

[// GUIDANCE: Add or delete definitions as local practice or institutional policy dictates.]

3. OPERATIVE PROVISIONS

3.1 Directive Not to Resuscitate
Upon Cardiopulmonary Arrest, Providers SHALL WITHHOLD all CPR measures and SHALL NOT attempt endotracheal intubation, defibrillation, cardiac drugs, or other life-sustaining resuscitation.

3.2 Permitted Comfort Measures
This Directive does NOT prohibit palliative or comfort-oriented care, including oxygen, pain control, anti-anxiety medication, suctioning, or other non-resuscitative treatments.

3.3 EMS Recognition
a. Declarant (or representative) shall maintain EMS Recognition Materials in an easily accessible location on Declarant’s person or residence.
b. Providers acting in Good Faith reliance on such materials are entitled to statutory immunity and other protections set forth herein.

3.4 Authorization by Clinician
Authorizing Clinician hereby enters a medical order consistent with Section 3.1 in Declarant’s medical record and, if applicable, on any state-mandated MOLST form.

3.5 Duty to Distribute
Declarant, or Declarant’s representative, shall furnish copies of this Directive to (i) each primary care provider; (ii) any treating facility; and (iii) close family members or caregivers as appropriate.

3.6 Revocation and Modification
a. Declarant may revoke this Directive AT ANY TIME by:
 (i) a written statement of revocation;
 (ii) an oral expression of intent to revoke in the presence of a Provider; or
 (iii) physically destroying the Directive or EMS Recognition Materials.
b. Revocation is effective immediately upon communication or destruction.
c. Any subsequent conflicting medical order (e.g., full code) signed by the Authorizing Clinician supersedes this Directive.

3.7 Conflict Resolution
In the event of conflicting instructions, Providers shall honor the LAST chronological, valid order presented, consistent with Connecticut law and medical ethics.

4. REPRESENTATIONS & WARRANTIES

4.1 Declarant
a. Competency: Declarant affirms capacity to execute this Directive.
b. Voluntariness: Declarant’s decision is voluntary, free of duress or undue influence.
c. Informed Decision: Declarant has discussed the medical implications of a DNR order with the Authorizing Clinician.

4.2 Authorizing Clinician
a. Medical Appropriateness: Clinician has determined the Directive is medically appropriate for Declarant.
b. Explanation: Clinician has explained foreseeable consequences of a DNR order to Declarant.
c. Record Entry: Clinician will promptly enter the order in Declarant’s permanent medical record.

4.3 Witnesses
Each witness (i) is at least eighteen (18) years old, (ii) is not the Authorizing Clinician, (iii) is not related to Declarant by blood, marriage, or adoption, and (iv) will not inherit from Declarant.

4.4 Survival
Sections 5 (Risk Allocation) and 6 (General Provisions) survive Revocation for acts or omissions occurring prior to the effective Revocation date.

5. RISK ALLOCATION

5.1 Provider Protection & Indemnification
Declarant and Declarant’s heirs, successors, and estate RELEASE, HOLD HARMLESS, and INDEMNIFY all Providers, to the fullest extent permitted by law, from civil, criminal, or administrative liability arising out of Good-Faith compliance with or reliance on this Directive.

5.2 Good-Faith Standard (Liability Cap)
No Provider shall be liable for monetary damages or subject to disciplinary action for either withholding resuscitative measures in accordance with this Directive or providing resuscitation in good-faith uncertainty about its validity.

5.3 Insurance
[OPTIONAL] Declarant shall maintain health-care or long-term-care insurance sufficient to cover palliative treatments and related expenses. Providers have no duty to verify such coverage.

6. GENERAL PROVISIONS

6.1 Governing Law
This Directive is governed by and construed in accordance with the health-care directive laws of the State of Connecticut without regard to conflict-of-laws principles.

6.2 Severability
If any provision is determined invalid or unenforceable, the remaining provisions remain in full force, and the invalid portion shall be conformed to the minimum necessary to be enforceable.

6.3 Reliance & Immunity
Providers may rely on photocopies, facsimiles, or electronic images of this Directive. Good-Faith reliance affords the same legal effect and immunity as possession of an original.

6.4 Amendments
Any amendment must (i) be in writing, (ii) reference this Directive, (iii) be signed by Declarant and Authorizing Clinician, and (iv) satisfy the witness requirements in Section 7.3.

6.5 Entire Agreement
This Directive, together with any properly executed MOLST or similar document, constitutes the entire directive of Declarant regarding resuscitation outside a hospital setting, superseding all prior oral or written directives on that subject.

6.6 Counterparts & Electronic Signatures
This Directive may be executed in multiple counterparts, each deemed an original. Signatures transmitted by reliable electronic means (e-signature, facsimile, PDF) are deemed originals.

7. EXECUTION BLOCK

[// GUIDANCE: Connecticut requires TWO ADULT WITNESSES; notarization is optional but recommended.]

7.1 Declarant

I, [PATIENT FULL LEGAL NAME], knowingly and voluntarily execute this Directive on the date written below.

Signature: _____ Date: _
Print Name: _____ DOB: ______

7.2 Authorizing Clinician

By signing, I affirm the medical order set forth in Section 3.1 and my representations in Section 4.2.

Signature: _____ Date: _
Print Name: ____ Title: __
License No.: ____ Phone: _____

7.3 Witnesses

We declare that (i) the Declarant signed or acknowledged this Directive in our presence, (ii) we are at least 18 years old and competent, (iii) we are not the Authorizing Clinician, and (iv) we are not related to Declarant nor entitled to any portion of Declarant’s estate.

Witness #1 Signature: ___ Date: _
Print Name: ______ Address: _

Witness #2 Signature: ___ Date: _
Print Name: ______ Address: _

7.4 Optional Notary Acknowledgment

State of Connecticut )
County of [COUNTY] ) ss. [TOWN] [DATE]

On this ___ day of ____, 20__, before me, the undersigned notary public, personally appeared [PATIENT NAME], known to me (or satisfactorily proven) to be the person whose name is subscribed to the foregoing Directive and acknowledged that (s)he executed the same for the purposes therein contained.

Notary Public: ______
My Comm’n Expires: _______

7.5 EMS Verification (Optional)

EMS Provider Name/ID: ___
Date & Time Reviewed: ___
Initials: ____

8. REVOCATION / MODIFICATION RECORD

[// GUIDANCE: Have Declarant and Clinician initial any changes; attach additional pages if needed.]

IMPORTANT INFORMATION FOR PROVIDERS

1. If uncertainty exists regarding validity, provide resuscitation until clarified.
2. If Declarant or authorized surrogate requests resuscitation, IMMEDIATELY HONOR that request and consider this Directive revoked.
3. Document all decisions and the presence or absence of Directive materials in the patient care report.

END OF DOCUMENT