IOWA OUT-OF-HOSPITAL
DO-NOT-RESUSCITATE (DNR) ORDER / MEDICAL DIRECTIVE
(“Directive”)
[// GUIDANCE: This template is designed to comply with Iowa Code § 144A (2023) (Life-Sustaining Procedures Act) and the Iowa Department of Public Health’s Out-of-Hospital DNR protocols. Customize all bracketed text, confirm current administrative forms, and attach any state-issued DNR wallet card or bracelet order form as Schedule 1.]
TABLE OF CONTENTS
- Document Header
- Definitions
- Operative Provisions
- Representations & Warranties
- Covenants & Restrictions
- Revocation, Suspension & Remedies
- Risk Allocation
- Governing Law & Dispute Resolution
- General Provisions
- Execution Block
- Schedules & Exhibits
1. DOCUMENT HEADER
1.1 Title. Iowa Out-of-Hospital Do-Not-Resuscitate Order / Medical Directive.
1.2 Parties.
(a) “Patient”: [PATIENT LEGAL NAME], DOB [MM/DD/YYYY], last four SSN [####], residing at [ADDRESS].
(b) “Authorized Representative” (if any): [NAME & RELATIONSHIP], acting under [Durable Power of Attorney for Health Care dated _ / Guardianship Letters dated _].
(c) “Attending Practitioner”: [NAME, CREDENTIALS], Iowa license no. [_____].
1.3 Effective Date. This Directive becomes effective on the latest signature date in § 10.
1.4 Recitals.
WHEREAS, Patient (or Authorized Representative) desires to refuse cardiopulmonary resuscitation (“CPR”) in the event of cardiopulmonary arrest, consistent with Iowa Code § 144A; and
WHEREAS, Attending Practitioner has determined that Patient is an appropriate candidate for an out-of-hospital DNR order;
NOW, THEREFORE, Patient, Authorized Representative, and Attending Practitioner agree as follows:
2. DEFINITIONS
Capitalized terms have the meanings set forth below.
“Advanced Cardiac Life Support” or “ACLS” means any resuscitative intervention beyond Basic Life Support.
“Authorized Representative” has the meaning ascribed in § 1.2(b).
“Comfort Care” means medical or palliative measures intended to alleviate pain or discomfort without attempting to restart or support respiration or circulation.
“Directive” means this Iowa Out-of-Hospital DNR Order, including all Schedules.
“EMS Personnel” means emergency medical technicians, paramedics, and any first responders licensed or certified under Iowa law.
“Revocation” has the meaning in § 6.1.
3. OPERATIVE PROVISIONS
3.1 Order Not to Initiate Resuscitation. In the event of cardiopulmonary arrest, EMS Personnel, health-care providers, and bystanders are instructed NOT to provide CPR, ACLS, defibrillation, advanced airway management, artificial ventilation, or other resuscitative measures. Only Comfort Care shall be rendered.
3.2 Scope; Out-of-Hospital Application. This Directive applies in all non-hospital settings, including but not limited to Patient’s residence, long-term care facilities, ambulances, and any public location within Iowa.
3.3 EMS Recognition. Pursuant to Iowa Department of Public Health protocol, a copy (including electronic image) of this signed Directive, a state-issued DNR wallet card, or an approved DNR bracelet/necklace SHALL constitute valid evidence for EMS Personnel to honor this order.
3.4 Display Requirement. Patient or Authorized Representative shall keep the original Directive in a prominent location and carry a copy when outside the residence.
3.5 Conditions Precedent. This Directive is operative only when:
(a) Patient experiences cardiopulmonary arrest; and
(b) EMS Personnel or health-care providers have identified a valid, unrevoked Directive.
3.6 No Effect on Comfort Care. Nothing herein limits the administration of oxygen, pain medication, suction, or other Comfort Care measures.
4. REPRESENTATIONS & WARRANTIES
4.1 Patient Representations. Patient represents that:
(a) Patient is at least 18 years of age (or an emancipated minor) and of sound mind;
(b) Execution is voluntary and not the result of duress or undue influence; and
(c) Patient has discussed the medical consequences of this Directive with the Attending Practitioner.
4.2 Practitioner Warranty. Attending Practitioner warrants that they have:
(a) Explained the nature, scope, and consequences of a DNR order;
(b) Determined, in professional judgment, that the order is medically appropriate; and
(c) Reviewed Patient’s or Authorized Representative’s consent prior to execution.
4.3 Survival. These representations survive the execution of this Directive.
5. COVENANTS & RESTRICTIONS
5.1 Patient Covenants. Patient or Authorized Representative shall:
(a) Provide copies of this Directive to all current health-care providers and facilities;
(b) Inform new providers or facilities of this Directive upon admission; and
(c) Immediately notify providers upon Revocation under § 6.1.
5.2 No Transfer Restrictions. This Directive shall not impede Patient’s right to transfer to a facility willing to comply with Patient’s overall treatment preferences.
6. REVOCATION, SUSPENSION & REMEDIES
6.1 Revocation. This Directive may be revoked at any time by:
(a) Patient (or Authorized Representative) verbally or in writing;
(b) Physical destruction of the Directive or state DNR identification; or
(c) Issuance of a superseding DNR or POLST form.
[// GUIDANCE: Under Iowa Code § 144A, revocation is effective immediately upon communication to medical personnel.]
6.2 Suspension During Procedures. At Patient’s election, this Directive is automatically suspended during surgical or other invasive procedures where anesthesia is administered, provided that Attending Practitioner documents the suspension in the medical record. The Directive resumes upon post-anesthesia recovery.
6.3 Provider Reliance; Good-Faith Immunity. Any provider or EMS Personnel acting in good-faith reliance on a facially valid Directive shall be immune from civil or criminal liability to the fullest extent permitted under Iowa Code § 144A.
6.4 Remedies. Equitable relief, including declaratory judgment, shall be the exclusive remedy for disputes arising from enforcement of this Directive.
7. RISK ALLOCATION
7.1 Indemnification of Providers. Patient hereby releases and agrees to indemnify Attending Practitioner, EMS Personnel, and any health-care facility from liability for withholding or withdrawing resuscitative measures in good-faith compliance with this Directive.
7.2 Limitation of Liability. No party shall be liable for consequential, punitive, or exemplary damages arising from compliance with or good-faith refusal to comply with an ambiguous or revoked Directive.
8. GOVERNING LAW & DISPUTE RESOLUTION
8.1 Governing Law. This Directive and any dispute hereunder shall be governed by and construed in accordance with the laws of the State of Iowa, without regard to choice-of-law principles.
8.2 Forum Selection. Any action concerning the validity or enforcement of this Directive shall be brought exclusively in the Iowa District Court for the county where Patient resides at the time of filing.
8.3 Jury Waiver. NOT APPLICABLE.
8.4 Arbitration. NOT APPLICABLE.
8.5 Injunctive Relief. A court of competent jurisdiction may issue injunctive or declaratory relief to enforce or clarify this Directive.
9. GENERAL PROVISIONS
9.1 Amendment. This Directive may be amended only by executing a new directive that complies with Iowa law.
9.2 Severability. If any provision is held invalid, the remaining provisions shall remain in full force.
9.3 Integration. This document constitutes the entire agreement concerning the subject matter and supersedes prior oral or written statements.
9.4 Copies. Photocopies and electronic copies (including facsimiles and PDF) of this executed Directive shall be as effective as an original.
9.5 Electronic Signatures. Electronic signatures compliant with Iowa Uniform Electronic Transactions Act are permissible only where accepted by receiving health-care providers and EMS Personnel.
10. EXECUTION BLOCK
[// GUIDANCE: Iowa accepts EITHER (i) two adult witnesses OR (ii) a notary. Witnesses may not be the Attending Practitioner, relative by blood or marriage, or entitled to any portion of Patient’s estate.]
A. PATIENT / AUTHORIZED REPRESENTATIVE
Signature: _____ Date: __
Printed Name & Relationship (if representative): __________
B. ATTENDING PRACTITIONER
I hereby issue this out-of-hospital DNR order.
Signature: _____ Date: __
Printed Name & Credentials: ______
License No.: _ Phone: ________
C. WITNESSES (Two required if no notary)
1. Witness #1 Signature: ___ Date:
Printed Name: _____ Address: _____
2. Witness #2 Signature: ___ Date: _
Printed Name: _____ Address: ______
— OR —
D. NOTARIZATION
State of Iowa, County of [__]
Subscribed and sworn before me on [DATE] by [NAME(S)].
Notary Public Signature: ___
Printed Name: ___ Commission Expires: _
11. SCHEDULES & EXHIBITS
Schedule 1 Iowa Department of Public Health Approved DNR Wallet Card / Bracelet Order Form
Schedule 2 (OPTIONAL) Recent Advance Directive or POLST
Schedule 3 (OPTIONAL) Durable Power of Attorney for Health Care
[END OF DOCUMENT]