Medical Directive - DNR

HAWAII DO NOT RESUSCITATE (DNR) DIRECTIVE

(Comfort-Care Only Order)

TABLE OF CONTENTS

1. Document Header
2. Definitions
3. Operative Provisions
4. Representations & Warranties
5. Covenants & Restrictions
6. Default & Remedies
7. Risk Allocation
8. General Provisions
9. Execution Block

1. DOCUMENT HEADER

1.1 Title. HAWAII DO NOT RESUSCITATE (DNR) DIRECTIVE (“Directive”).

1.2 Parties.
a. “[PATIENT NAME]” (“Declarant” or “Patient”), currently residing at [ADDRESS], being of sound mind and at least eighteen (18) years of age; and
b. “[AUTHORISED HEALTH CARE PROVIDER NAME], [M.D./D.O./APRN]” (“Primary Provider”).

1.3 Effective Date; Jurisdiction. This Directive becomes effective on the latest date of execution set forth in Section 9 (Execution Block) (“Effective Date”) and shall be governed by the laws of the State of Hawaiʻi, including but not limited to HRS ch. 327E.

1.4 Recitals.
WHEREAS, Patient desires to ensure that no cardiopulmonary resuscitation (“CPR”) or advanced cardiac life support be administered in the event of cardiac or respiratory arrest;
WHEREAS, Primary Provider has determined, consistent with accepted medical standards, that honoring this wish is ethically and medically appropriate; and
WHEREAS, Hawaiʻi EMS personnel are authorized to rely upon a valid “Comfort-Care Only” DNR order pursuant to HRS § 327E-13 and DOH rules;
NOW, THEREFORE, Patient issues this Directive, and Primary Provider and all covered Health-Care Providers are instructed to comply in good faith with its terms.

2. DEFINITIONS

For purposes of this Directive, the following capitalized terms have the meanings set forth below:

“Advance Health-Care Directive” means a written instrument meeting HRS ch. 327E requirements that states a Principal’s health-care decisions, including a DNR order.

“Authorized Health-Care Provider” means a physician (M.D. or D.O.) or advanced practice registered nurse (APRN) licensed in Hawaiʻi who has primary responsibility for the Patient’s care or who otherwise has examined the Patient.

“Cardiopulmonary Resuscitation” or “CPR” means chest compressions, artificial ventilation, defibrillation, administration of cardiac drugs, or any other procedure intended to restart or support heart or breathing functions.

“Comfort Measures” means treatment to relieve pain or provide palliative care that does not attempt to cure or reverse the underlying medical condition.

“Emergency Medical Services” or “EMS” means state-licensed pre-hospital emergency responders, including paramedics, emergency medical technicians (EMTs), and first responders operating under HRS ch. 321.

“Good Faith” has the meaning set forth in HRS § 327E-2 and, for liability purposes, includes “honest belief” and “reasonable care” under the circumstances.

“Health-Care Provider” has the meaning assigned in HRS § 327E-2 and includes hospitals, nursing homes, physicians, nurses, EMTs, and any person licensed to provide health care.

“POLST” means Physician Orders for Life-Sustaining Treatment, a distinct medical order set recognized in Hawaiʻi; it is separate from, but may coexist with, this Directive.

3. OPERATIVE PROVISIONS

3.1 Do-Not-Resuscitate Order. Patient directs that no CPR be attempted in the event of cardiac or respiratory arrest. All Health-Care Providers, including EMS personnel, shall consider this Directive a current medical order.

3.2 Comfort-Care Only Authorization. Providers shall continue or initiate any Comfort Measures reasonably necessary to alleviate pain or suffering and to provide for Patient dignity.

3.3 EMS Recognition & Identification.
a. Presentation. This Directive (or DOH-approved DNR bracelet/necklace) constitutes official DNR identification under HRS § 327E-13.
b. Reliance. EMS personnel acting in Good Faith may rely on an original, legible copy, or approved electronic image of this Directive.

3.4 Scope of Treatment Limitation. This Directive applies only to resuscitative measures. It does not affect:
i. Treatment of choking;
ii. Administration of oxygen prior to respiratory or cardiac arrest;
iii. Pain control, palliative care, or other Comfort Measures; or
iv. Nutritional or hydration support except as separately ordered.

3.5 Revocation. Patient may revoke this Directive at any time by (i) oral or written notice to any Health-Care Provider, (ii) physical destruction of the Directive or DNR identification, or (iii) execution of a subsequent, conflicting order.

3.6 Review and Renewal. Primary Provider shall review the continued applicability of this Directive at each substantive change in Patient’s condition or care setting, and at minimum every twelve (12) months.

3.7 Copies and Electronic Records. Original, duplicate, and electronic copies duly executed shall have equal force and effect.

4. REPRESENTATIONS & WARRANTIES

4.1 Patient Capacity. Patient represents that they are of legal age, understand the nature and consequences of this Directive, and are executing it voluntarily.

4.2 Provider Determination. Primary Provider represents that (i) they have discussed the medical implications of CPR and alternatives with Patient (and, if applicable, Patient’s legally recognized surrogate), and (ii) issuance of this Directive accords with the standard of care.

4.3 No Conflicts. Each signatory warrants that execution of this Directive does not violate any court order, guardianship limitation, or applicable law.

4.4 Survival. The representations and warranties in this Section survive the death or incapacity of Patient for purposes of enforcing provider immunity and Good-Faith protections.

5. COVENANTS & RESTRICTIONS

5.1 Notification Covenant. Patient (or Patient’s Agent) shall inform subsequent Health-Care Providers and care facilities of the existence of this Directive and supply a copy upon admission or transfer.

5.2 Provider Documentation. Each Health-Care Provider who receives a copy of this Directive shall document its receipt in the Patient’s medical record.

5.3 No Unilateral Modification. No Health-Care Provider may modify or suspend this Directive absent Patient revocation, applicable court order, or as otherwise permitted by HRS ch. 327E.

6. DEFAULT & REMEDIES

6.1 Breach. Failure by any Provider to honor this Directive in Good Faith constitutes non-compliance with Patient’s legally protected health-care decision.

6.2 Remedy. Patient (or Patient’s estate) retains all civil remedies available under Hawaiʻi law; provided, however, that any Provider acting in Good Faith and substantial compliance with this Directive shall be immune from civil or criminal liability pursuant to HRS § 327E-15.

6.3 Notice & Cure. Where time permits (e.g., non-emergent settings), a Provider who questions the validity of this Directive shall immediately (i) consult the Primary Provider or Medical Director, and (ii) allow reasonable time for clarification before initiating CPR.

7. RISK ALLOCATION

7.1 Provider Protection & Indemnification. Patient agrees to hold harmless and indemnify any Health-Care Provider or EMS personnel who, in Good Faith reliance on this Directive, withhold CPR in accordance with its terms.

7.2 Limitation of Liability. No Provider shall be liable for acts or omissions undertaken in Good Faith compliance with this Directive, except in cases of gross negligence, willful misconduct, or violations of HRS ch. 327E.

7.3 Insurance. Nothing herein requires Patient to procure insurance; likewise, no insurer may limit coverage to a Provider solely because the Provider honored this Directive.

8. GENERAL PROVISIONS

8.1 Entire Agreement. This Directive, together with any valid POLST or Advance Health-Care Directive executed by Patient, constitutes the entire understanding regarding resuscitation preferences.

8.2 Amendments. Any amendment must (i) be in writing, (ii) reference this Directive’s Effective Date, and (iii) be signed by Patient and an Authorized Health-Care Provider.

8.3 Severability. If any provision of this Directive is found unenforceable, the remaining provisions shall remain in full force, provided they can be given effect without the invalid provision.

8.4 Counterparts & Electronic Signatures. This Directive may be executed in counterparts and by electronic signature, each of which shall be deemed an original.

8.5 Delivery. Transmission of a signed copy by facsimile, e-mail (PDF), or other reliable electronic means shall constitute lawful delivery.

9. EXECUTION BLOCK

9.1 Patient/Declarant

I, the undersigned Patient, have read and understand this Directive and voluntarily sign it on the date indicated.

9.2 Primary Authorized Health-Care Provider

I, the undersigned Provider, affirm that the Patient has decision-making capacity (or that the appropriate surrogate has consented), that CPR has been discussed, and that a DNR order is medically appropriate.

9.3 Witness OR Notary

Select ONE of the following options:

A. Witness Attestation
“I declare under penalty of perjury that (i) the Patient executed this Directive in my presence, (ii) the Patient appeared to be of sound mind and under no duress, and (iii) I meet the statutory qualifications to serve as a witness.”

B. Notary Acknowledgment
State of Hawaiʻi )
City & County of ☐ )

On this _____ day of __________, 20____, before me appeared [PATIENT NAME], personally known to me (or satisfactorily proven) to be the person whose name is subscribed to this Directive, and acknowledged that they executed the same for the purposes therein contained.

End of Document