GEORGIA DO NOT RESUSCITATE (DNR) ORDER & MEDICAL DIRECTIVE
Template – For Attorney Customization
[// GUIDANCE: This template is drafted for use in the State of Georgia and is intended to comply with O.C.G.A. § 31-39-1 et seq. (“Georgia DNR Law”). Verify all facts, execution formalities, and client instructions before finalizing.]
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TABLE OF CONTENTS
- Document Header...............................................2
- Definitions...................................................3
- Operative Provisions..........................................4
- Representations & Warranties..................................5
- Covenants & Restrictions......................................6
- Default & Remedies............................................7
- Risk Allocation...............................................7
- Dispute Resolution............................................8
- General Provisions............................................8
- Execution Block...............................................9
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1. DOCUMENT HEADER
1.1 Title
GEORGIA DO NOT RESUSCITATE (DNR) ORDER & MEDICAL DIRECTIVE (the “Directive”).
1.2 Parties
a. “Patient”: [INSERT LEGAL NAME], residing at [ADDRESS].
b. “Attending Physician”: [PHYSICIAN NAME], Georgia medical license no. [NUMBER].
c. “Health-Care Provider(s)”: Collectively, all licensed facilities, practitioners, and emergency medical services (“EMS”) personnel who may attend to the Patient.
1.3 Recitals
WHEREAS, Patient is a competent adult with decisional capacity and desires, in the event of cardiopulmonary arrest, not to receive cardiopulmonary resuscitation (“CPR”);
WHEREAS, Georgia law authorizes a documented DNR order to be issued and honored by Health-Care Providers acting in good faith;
NOW, THEREFORE, in consideration of the mutual covenants herein and intending to be legally bound, Patient and Attending Physician execute this Directive effective as of [EFFECTIVE DATE].
1.4 Jurisdiction
This Directive shall be governed by and construed in accordance with the laws of the State of Georgia, specifically O.C.G.A. Title 31, Chapter 39.
[// GUIDANCE: Forum selection, arbitration, and jury waiver are intentionally noted as “not applicable” per user metadata.]
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2. DEFINITIONS
“Cardiopulmonary Resuscitation” or “CPR” means cardiac compression, tracheal intubation, ventilation, defibrillation, or medication administered for the purpose of restarting the heart or breathing.
“DNR Order” means a physician’s written order, executed in accordance with O.C.G.A. § 31-39-4, directing that CPR shall not be attempted.
“EMS Recognition” means compliance with Georgia Department of Public Health requirements such that the original DNR Order or approved DNR bracelet/necklace is presented to EMS personnel.
“Good Faith Standard” means the degree of care that a reasonably prudent provider would exercise under similar circumstances, consistent with O.C.G.A. § 31-39-7.
“Provider Protection” refers to statutory immunity bestowed on Health-Care Providers who honor this Directive in good faith.
“Witness” means an individual who is at least eighteen (18) years old, competent, not designated to make health-care decisions for the Patient, and not directly involved in Patient’s health-care finances.
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3. OPERATIVE PROVISIONS
3.1 DNR ORDER
a. The Attending Physician hereby orders that no CPR be attempted on the Patient in the event of cardiopulmonary arrest.
b. This DNR Order is valid in all health-care settings, including but not limited to hospitals, nursing homes, outpatient facilities, ambulances, and the Patient’s residence.
3.2 EMS RECOGNITION
Health-Care Providers and EMS personnel shall honor this Directive upon presentation of:
i. The original, conspicuously signed Directive; or
ii. A DPH-approved DNR bracelet/necklace bearing Patient’s name and the words “Georgia DNR.”
3.3 SCOPE OF NON-INTERVENTION
The following interventions shall not be withheld unless separately specified:
a. Pain management or comfort-care measures;
b. Non-invasive oxygen supplementation;
c. Bleeding control;
d. Airway suctioning.
[// GUIDANCE: Insert or remove additional treatments the Patient wishes to refuse or accept.]
3.4 DURATION
This Directive remains in effect until revoked pursuant to Section 5.3.
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4. REPRESENTATIONS & WARRANTIES
4.1 Patient Representations
a. The Patient is at least eighteen (18) years of age or otherwise legally emancipated.
b. The Patient is of sound mind and acting voluntarily.
4.2 Physician Representations
a. The Attending Physician has verified Patient’s decisional capacity immediately prior to execution.
b. The DNR Order complies with all requirements of O.C.G.A. § 31-39-4.
4.3 Provider Reliance
Health-Care Providers may rely on the authenticity of this Directive and are entitled to statutory immunity when acting in good faith.
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5. COVENANTS & RESTRICTIONS
5.1 Patient Covenant to Notify
Patient (or Health-Care Agent) shall inform future treating providers of this Directive and provide copies as necessary.
5.2 Provider Covenant to Document
All Health-Care Providers shall place a copy of this Directive in the Patient’s permanent medical record and flag the chart “DNR.”
5.3 Revocation
a. Patient may revoke this Directive at any time by:
i. A signed, dated writing;
ii. Physical destruction of the Directive; or
iii. A verbal statement to Health-Care Providers in the presence of at least two (2) adult Witnesses.
b. Revocation is effective immediately upon communication to the Attending Physician or EMS personnel.
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6. DEFAULT & REMEDIES
6.1 Event of Default
A material default occurs if CPR is administered to Patient contrary to Section 3.1.
6.2 Remedies
a. Equitable Relief: Patient (or Health-Care Agent) may seek injunctive or declaratory relief to enforce this Directive.
b. Statutory Immunity: Health-Care Providers acting in good faith are immune from civil or criminal liability per O.C.G.A. § 31-39-6.
c. Costs & Fees: A prevailing party in enforcement litigation may recover reasonable attorney fees and costs.
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7. RISK ALLOCATION
7.1 Indemnification
Patient agrees to indemnify and hold harmless any Health-Care Provider who, in good faith, complies with this Directive, from any claim arising out of such compliance, except for gross negligence or willful misconduct.
7.2 Limitation of Liability
No Health-Care Provider shall be liable for punitive or exemplary damages for honoring this Directive in good faith.
7.3 Insurance
[OPTIONAL PLACEHOLDER – insert malpractice coverage confirmation if required by institution.]
7.4 Force Majeure
The failure of Health-Care Providers to honor this Directive due to circumstances beyond their control (e.g., lost document, unknown status) shall not constitute a breach, provided reasonable efforts to ascertain DNR status were made.
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8. DISPUTE RESOLUTION
8.1 Governing Law
This Directive is governed by the laws of the State of Georgia.
8.2 Forum
Any dispute shall be filed in a court of competent jurisdiction located in [COUNTY], Georgia.
8.3 Injunctive Relief
Nothing herein limits a party’s right to seek temporary, preliminary, or permanent injunctive relief to enforce the terms of this Directive.
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9. GENERAL PROVISIONS
9.1 Amendment
This Directive may be amended only by a new writing executed with the same formalities as this Directive.
9.2 Assignment
Rights and obligations hereunder are personal and may not be assigned.
9.3 Severability
If any provision is held invalid, the remaining provisions shall remain in full force to the fullest extent permitted.
9.4 Integration
This Directive constitutes the entire agreement regarding the withholding of CPR and supersedes all prior oral or written statements on that subject.
9.5 Counterparts; Electronic Signatures
This Directive may be executed in counterparts, including PDF or electronic signatures, each of which shall be deemed an original.
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10. EXECUTION BLOCK
10.1 PATIENT
I, the undersigned Patient, affirm that I have read and understand this Directive and that it reflects my clear and unequivocal wish not to receive CPR.
Signature: ____ Date: __
Printed Name: _________
10.2 ATTENDING PHYSICIAN
I, the undersigned Physician, certify that the Patient has decisional capacity and that this Directive is executed in accordance with Georgia law.
Signature: ____ Date: __
Printed Name: _____
License No.: _____
Phone: _______
10.3 WITNESSES
We declare that the Patient signed (or acknowledged signing) this Directive in our presence and appears to be of sound mind and acting voluntarily.
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Witness Signature: ____ Date: __
Printed Name & Address: _____ -
Witness Signature: ____ Date: __
Printed Name & Address: _____
[// GUIDANCE: Neither witness may be (i) a person named herein to make health-care decisions, (ii) related by blood, marriage, or adoption to the Patient, or (iii) entitled to any portion of the Patient’s estate.]
10.4 EMS/DNR IDENTIFICATION (Optional but Recommended)
Serial No. of DPH-Approved DNR Bracelet/Necklace: ______
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[END OF DOCUMENT]