ILLINOIS DO-NOT-RESUSCITATE (DNR) ADVANCE MEDICAL DIRECTIVE
[Illinois Department of Public Health (“IDPH”) Uniform Format]
[// GUIDANCE: This template tracks the structure of the IDPH-approved Uniform DNR/POLST order while adding optional risk-management language and placeholders for attorney customization. Remove bracketed text that is not applicable before finalizing.]
TABLE OF CONTENTS
- Document Header
- Definitions
- Operative Provisions
- Representations & Warranties
- Covenants & Restrictions
- Default & Remedies
- Risk Allocation
- Dispute Resolution
- General Provisions
- Execution Block
1. DOCUMENT HEADER
1.1 Title. ILLINOIS DO-NOT-RESUSCITATE (DNR) ADVANCE DIRECTIVE (IDPH Uniform Form).
1.2 Parties.
(a) “Patient”: [FULL LEGAL NAME] (“Patient”)
(b) “Authorized Agent/Surrogate”: [NAME] (if any) (“Agent”)
(c) “Attending Practitioner”: [PHYSICIAN/APRN/PA NAME] (“Practitioner”)
(d) “Health-Care Providers”: All emergency medical services (“EMS”), hospitals, long-term-care facilities, and individual clinicians that may render treatment to the Patient (collectively, “Providers”).
1.3 Recitals.
A. Patient, being of sound mind or acting through a duly authorized Agent, desires to direct that no cardiopulmonary resuscitation (“CPR”) or advanced cardiac life support be attempted in the event of cardiac or respiratory arrest.
B. Illinois law and IDPH administrative rules authorize a uniform DNR advance directive that EMS personnel must honor when executed in proper form with required signatures and witnesses.
C. Practitioner has reviewed the Patient’s medical condition, treatment options, and prognosis with the Patient/Agent and finds that entry of a DNR order is clinically appropriate and legally compliant.
1.4 Effective Date. This Directive is effective on the later of (i) the date signed by the Patient/Agent, or (ii) the date signed by the Practitioner (“Effective Date”), and remains in force until revoked pursuant to Section 3.6.
1.5 Governing Law. This Directive is governed exclusively by the laws of the State of Illinois applicable to health-care directives and emergency medical services.
2. DEFINITIONS
“Agent” has the meaning set forth in 755 ILCS 45/4-4a or any successor Illinois statute governing health-care power of attorney.
“Cardiac Arrest” means the absence of a palpable pulse or other signs of circulation.
“CPR” means chest compressions, defibrillation, cardiac medications, and/or artificial ventilation intended to restore cardiac or respiratory function.
“EMS” means licensed emergency medical services personnel operating under Illinois EMS Systems.
“Good Faith” means honesty in fact and the reasonable belief that an action is in accord with applicable medical standards and legal requirements.
“Practitioner” means a licensed physician, advanced practice registered nurse, or physician assistant with authority under Illinois law to issue medical orders.
“Providers” has the meaning set forth in Section 1.2(c).
3. OPERATIVE PROVISIONS
3.1 DNR Order. In the event of Cardiac or Respiratory Arrest, Providers shall withhold CPR and related life-sustaining interventions.
3.2 Scope of Treatment While Breathing and/or Heartbeat Present.
[ ] a. Comfort-Focused Care Only – No artificial ventilation, intubation, or ICU transfer.
[ ] b. Limited Interventions – May include non-invasive ventilation, IV fluids, or antibiotics, but no intubation or CPR.
[ ] c. Full Treatment Except CPR – All medically indicated treatments may be provided until the point of arrest.
[// GUIDANCE: Check one box. Strike alternatives that do not apply.]
3.3 Artificial Nutrition & Hydration (Optional).
[ ] Provide temporary artificial nutrition/hydration.
[ ] Withhold artificial nutrition/hydration.
3.4 EMS Recognition. A legible copy or original printed on distinctive [COLOR—commonly bright pink] paper, bearing required signatures and witness attestations, shall constitute a valid medical order that EMS must honor statewide.
3.5 Review & Renewal. Practitioner shall review this Directive periodically, and at minimum when: (i) the Patient is transferred between care settings; (ii) the Patient’s diagnosis or prognosis materially changes; or (iii) the Patient/Agent requests review.
3.6 Revocation. The Patient or Agent may revoke this Directive at any time by (i) expressing intent to revoke, (ii) physically destroying all copies, or (iii) executing a superseding directive. Revocation is effective upon communication to any Provider.
4. REPRESENTATIONS & WARRANTIES
4.1 Patient/Agent represents that:
(a) Patient is at least 18 years of age or an emancipated minor;
(b) Patient has decision-making capacity or is represented by a duly appointed Agent;
(c) No coercion or undue influence was exerted in executing this Directive.
4.2 Practitioner represents that:
(a) Practitioner has explained the nature and consequences of a DNR order;
(b) Practitioner believes the order is medically appropriate; and
(c) Practitioner has completed all documentation required by Illinois law and IDPH guidance.
4.3 Survival. Representations and warranties survive revocation only to the extent necessary to protect Providers who relied on them while the Directive was in force.
5. COVENANTS & RESTRICTIONS
5.1 Patient/Agent covenants to:
(a) Provide copies of this Directive to all current Providers;
(b) Inform family members of the Directive’s existence and terms; and
(c) Promptly notify Providers if the Directive is revoked or superseded.
5.2 Providers covenant to act in Good Faith compliance with this Directive, subject to standard of care and applicable ethical guidelines.
6. DEFAULT & REMEDIES
6.1 Event of Default. Any material breach of Sections 5.1 or 5.2 constitutes an “Event of Default.”
6.2 Notice & Cure. The non-breaching party shall give prompt written notice of default. The breaching party shall have a reasonable opportunity, not to exceed 24 hours where medically feasible, to cure the default.
6.3 Remedies.
(a) Specific Performance. Because monetary damages are inadequate, parties may seek injunctive relief to enforce or enjoin non-compliant treatment.
(b) Costs. A prevailing party is entitled to recover reasonable attorneys’ fees and costs incurred to enforce this Directive.
7. RISK ALLOCATION
7.1 Indemnification. Patient/Agent shall indemnify and hold harmless Providers and Practitioner from any civil or criminal liability arising out of Good Faith compliance with this Directive, except for willful or wanton misconduct.
7.2 Limitation of Liability. No Provider or Practitioner acting in Good Faith shall be liable for (i) withholding or withdrawing CPR in accordance with this Directive, or (ii) CPR rendered in the absence of knowledge of this Directive.
7.3 Insurance. Providers shall maintain professional liability coverage in accordance with Illinois law; no separate insurance is required under this Directive.
7.4 Force Majeure. A Provider’s inability to comply due to circumstances beyond its control (e.g., mass-casualty event) shall not constitute a breach.
8. DISPUTE RESOLUTION
8.1 Governing Law. This Directive is governed by the internal laws of the State of Illinois, without regard to its conflict-of-law principles.
8.2 Forum. Any action relating to this Directive shall be brought in a court of competent jurisdiction located in the county where treatment was rendered.
8.3 Injunctive Relief. Nothing herein limits the right of any party to seek emergent injunctive relief to enforce Section 3.
9. GENERAL PROVISIONS
9.1 Amendment. Only the Patient or Agent, with Practitioner consent, may amend this Directive, and any amendment must satisfy the same execution formalities as the original.
9.2 Assignment. Rights and obligations hereunder are personal and non-assignable.
9.3 Severability. If any provision is held unenforceable, the remaining provisions shall remain in full force, and the unenforceable provision shall be reformed to the minimum extent necessary to comply with applicable law.
9.4 Integration. This Directive constitutes the entire agreement concerning its subject matter and supersedes all prior DNR orders.
9.5 Counterparts & Electronic Signatures. This Directive may be executed in counterparts and by electronic signature with the same effect as an original.
10. EXECUTION BLOCK
[// GUIDANCE: Two witnesses are recommended under IDPH guidance. Neither witness may be the Practitioner, the Agent, nor an employee of a facility in which the Patient resides (with certain narrow statutory exceptions).]
10.1 Patient / Agent Signature
I certify that I have read this Directive, understand its purpose, and voluntarily execute it.
Patient Signature: _____ Date: _
OR
Agent Signature: _____ Date: _
Printed Name & Authority: _______
10.2 Practitioner Signature (Required)
I affirm that this order is medically appropriate and complies with Illinois law.
Practitioner Signature: ___ Date: _
Printed Name & Credentials: ______
License No.: ___ Phone: ___
10.3 Witness Attestation
We, the undersigned, declare under penalty of perjury that (i) the Patient/Agent voluntarily signed this Directive in our presence; (ii) the signatory appeared to be of sound mind and free from duress; and (iii) we are not disqualified witnesses under Illinois law.
Witness #1 Signature: ____ Date: _
Printed Name: _____
Address: __________
Witness #2 Signature: ____ Date: _
Printed Name: _____
Address: __________
[// GUIDANCE:
1. File the executed original in the Patient’s medical record and provide copies to EMS, family, and facility staff.
2. For EMS recognition, ensure the document is printed on the prescribed color paper (commonly bright pink) or affix an approved IDPH label/sticker if electronic.
3. Review at least annually, upon change of care setting, or if the Patient’s wishes evolve.]