DISTRICT OF COLUMBIA
DO NOT RESUSCITATE (DNR) DIRECTIVE & PROVIDER ORDER
[// GUIDANCE: This template is designed to satisfy the District of Columbia Uniform Health-Care Decisions framework and the Department of Health (“DOH”) Comfort Care/Do-Not-Resuscitate Order program, including EMS recognition rules. Customize all bracketed text, and confirm local procedural updates before execution.]
TABLE OF CONTENTS
- Document Header
- Definitions
- Operative Provisions (Directive & Orders)
- Representations & Acknowledgments
- Provider Protection & Liability Allocation
- Revocation, Amendment & Reassessment
- General Provisions
- Execution Block
1. DOCUMENT HEADER
1.1 Title. District of Columbia Do Not Resuscitate (DNR) Directive & Provider Order (“Directive”).
1.2 Parties.
a. “Patient”: [PATIENT FULL LEGAL NAME], DOB [MM/DD/YYYY], residing at [ADDRESS].
b. “Authorized Decision-Maker” (if other than Patient): [AGENT/SURROGATE NAME], acting pursuant to [identify instrument or relationship].
c. “Attending Physician/Advanced Practice Registered Nurse (APRN)”: [PROVIDER NAME], DC License No. [LICENSE #].
1.3 Effective Date. This Directive takes effect on the later of (i) the date signed by the Patient or Authorized Decision-Maker, or (ii) the date countersigned by the Attending Physician/APRN (the “Effective Date”).
1.4 Governing Law & Jurisdiction. This Directive shall be interpreted under the laws of the District of Columbia governing health-care decisions and provider DNR orders.
2. DEFINITIONS
For purposes of this Directive, capitalized terms have the meanings set forth below. Defined terms appear alphabetically.
“Comfort Care” – any medically indicated measure intended to alleviate pain or provide palliative benefit, including oxygen, analgesia, and positioning, but expressly excluding CPR as defined herein.
“CPR” – cardiopulmonary resuscitation, including chest compressions, defibrillation, advanced airway management, artificial ventilation, and administration of cardiac resuscitative drugs.
“DNR” – an instruction that no CPR be attempted if the Patient experiences cardiac or respiratory arrest.
“EMS” – the District of Columbia Fire and Emergency Medical Services Department, and any other emergency medical personnel authorized to provide pre-hospital care within the District.
“Good-Faith Compliance” – action taken in objective reliance on a facially valid Directive, without actual knowledge of revocation or invalidity.
“Health-Care Provider” – any person or entity licensed or authorized to administer health-care services, including hospitals, long-term-care facilities, physicians, APRNs, physician assistants, and EMS personnel.
“Revocation” – any act described in Section 6.1 that renders this Directive null and void.
3. OPERATIVE PROVISIONS (DIRECTIVE & ORDERS)
3.1 Statement of Intent. The Patient, having capacity and acting voluntarily, or the Authorized Decision-Maker acting within lawful authority, directs that no CPR be initiated in the event of cardiac or respiratory arrest.
3.2 Provider Order. The Attending Physician/APRN hereby orders all Health-Care Providers, including EMS, to withhold CPR in accordance with this Directive.
3.3 Scope of Medical Interventions.
a. Withhold: CPR, intubation for resuscitative purposes, electric cardioversion/defibrillation, vasoactive resuscitative medications.
b. Permit: Comfort Care, including but not limited to supplemental oxygen, pain control, hemorrhage control, and emotional support.
3.4 Location of Applicability. This Directive is effective in all health-care settings within the District of Columbia and during transport by EMS.
3.5 Presentation to EMS. The Patient or caregiver shall present either:
i. The originally executed Directive, or
ii. A DC-approved DNR identification (bracelet, necklace, or wallet card) referencing this Directive’s order number [ORDER #].
3.6 Conditions Precedent. This Directive is contingent on verification of (i) Patient identity, and (ii) absence of a known Revocation.
3.7 Duration. This Directive remains in force until revoked pursuant to Section 6 or until superseded by a more recent DNR order.
4. REPRESENTATIONS & ACKNOWLEDGMENTS
4.1 Capacity & Voluntariness. The Patient affirms, or the Authorized Decision-Maker certifies, that the Patient (i) is at least 18 years of age or otherwise emancipated, and (ii) executes this Directive voluntarily and without undue influence.
4.2 Understanding of Consequences. The signatory acknowledges understanding that:
a. CPR will not be initiated if arrest occurs;
b. Absence of CPR may hasten death;
c. Comfort Care will still be provided.
4.3 Provider Counseling. The Attending Physician/APRN affirms having discussed the Patient’s medical condition, prognosis, and the likely benefits and burdens of CPR versus Comfort Care.
5. PROVIDER PROTECTION & LIABILITY ALLOCATION
5.1 Good-Faith Immunity. Any Health-Care Provider, including EMS personnel, who honors or refrains from honoring this Directive in Good-Faith Compliance shall not incur civil or criminal liability, nor be subject to professional discipline, for such action or inaction.
5.2 Indemnification. The Patient (or the Patient’s estate) shall indemnify and hold harmless any Health-Care Provider from claims, damages, or expenses arising from Good-Faith Compliance, except in cases of gross negligence or willful misconduct.
5.3 Limitation of Liability. No Health-Care Provider acting in Good-Faith Compliance shall be liable for consequential, incidental, punitive, or exemplary damages. Liability, if any, shall be limited to actual damages proximately caused by gross negligence or willful misconduct.
[// GUIDANCE: Section 5 aligns with the metadata directive “provider_protection / good_faith_standard.” Delete or modify if inconsistent with client objectives or governing law updates.]
6. REVOCATION, AMENDMENT & REASSESSMENT
6.1 Revocation Methods. This Directive may be revoked by any of the following, effective upon communication to a Health-Care Provider:
a. A written, signed, and dated statement of revocation by the Patient or Authorized Decision-Maker;
b. Physical destruction of this Directive by the Patient or at the Patient’s direction;
c. Oral expression of intent to revoke, made in the presence of a Health-Care Provider;
d. Execution of a subsequent DNR directive or order.
6.2 Amendment. Any amendment must (i) be in writing, (ii) clearly identify the provisions amended, and (iii) be executed with the same formalities as the original Directive.
6.3 Periodic Reassessment. The Attending Physician/APRN shall review the continuing appropriateness of this Directive at each significant change in the Patient’s health status or care setting, and in any event no less frequently than annually.
7. GENERAL PROVISIONS
7.1 Severability. If any provision of this Directive is held invalid or unenforceable, the remaining provisions shall remain in full force and effect.
7.2 Integration. This Directive constitutes the entire agreement and supersedes all prior DNR directives or orders concerning the Patient, except to the extent expressly incorporated herein.
7.3 Amendment & Waiver. No amendment or waiver of any provision shall be effective unless executed in accordance with Section 6.2. No failure to enforce shall constitute a waiver.
7.4 Counterparts & Electronic Signatures. This Directive may be executed in counterparts, each of which is deemed an original. Signatures transmitted by facsimile, PDF, or secure electronic signature platform shall be deemed originals to the extent permitted by District law.
7.5 Delivery. A copy of this Directive shall be placed in the Patient’s medical record and communicated to all treating facilities and EMS providers reasonably likely to render care.
8. EXECUTION BLOCK
[// GUIDANCE: DC DOH regulations require at least ONE witness who is NOT (i) the attending physician/APRN, (ii) an employee of a health-care facility where the Patient is receiving care, or (iii) a person entitled to any portion of the Patient’s estate. Many practitioners still obtain two witnesses for belt-and-suspenders protection.]
8.1 Patient / Authorized Decision-Maker
I have read and understand this Directive and affirm my intent that it be honored.
| Signature | Printed Name | Date |
|---|---|---|
| ________ | ________ | _____ |
Relation to Patient (if not Patient): ________
8.2 Witness(es)
I declare under penalty of perjury that the individual signing above executed this Directive voluntarily, appeared to be of sound mind, and was not unduly influenced.
| Witness # | Signature | Printed Name | Address | Date |
|---|---|---|---|---|
| 1 | ______ | ______ | ______ | _____ |
| 2 | ______ | ______ | ______ | _____ |
8.3 Attending Physician / APRN Order
Pursuant to my clinical judgment and the Patient’s expressed wishes, I order that no CPR be performed and that Comfort Care be provided as indicated herein.
| Signature | Printed Name & Credentials | DC License # | Telephone | Date & Time |
|---|---|---|---|---|
| ________ | ________ | _____ | _____ | _____ |
EMS RECOGNITION CERTIFICATION
This Directive meets the requirements of the DC DOH Comfort Care/DNR protocol. EMS personnel are authorized to honor this order in accordance with applicable regulations.
Initials of Physician/APRN: ___ Date: _____
[// GUIDANCE:
1. File the original in the patient’s medical chart; give copies to the patient, surrogate, primary care physician, and each facility.
2. Offer the DOH-approved DNR bracelet or wallet card.
3. Review the Directive upon each admission or significant change in health status.
4. For patients transferred out of DC, verify reciprocity under the receiving jurisdiction’s EMS rules.
]