OUT-OF-HOSPITAL DO NOT RESUSCITATE (DNR) ORDER
State of Indiana
[// GUIDANCE: This template is drafted to comply with current Indiana requirements for Out-of-Hospital DNR orders, including form content, witness formalities, and EMS recognition standards. Customize bracketed fields, remove guidance comments prior to execution, and attach any state-issued “DNR bracelet” or wallet-card forms where required.]
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.
OUT-OF-HOSPITAL DO NOT RESUSCITATE ORDER AND MEDICAL DIRECTIVE (the “Directive”).
1.2 Parties.
(a) [PATIENT NAME], an individual with residence at [ADDRESS] (“Patient”);
(b) [AUTHORIZED REPRESENTATIVE NAME] (if any), acting pursuant to [specify authority, e.g., Power of Attorney for Health Care] (“Representative”); and
(c) [ATTENDING PHYSICIAN NAME], M.D./D.O., Indiana license no. [NUMBER] (“Physician”).
1.3 Recitals.
A. Patient desires that no cardiopulmonary resuscitation (“CPR”) or advanced cardiac life support be attempted if Patient experiences cardiopulmonary arrest outside a hospital setting.
B. Indiana law authorizes a competent adult, or an authorized representative, together with the attending physician, to execute a do-not-resuscitate order effective in out-of-hospital environments.
C. Physician, having determined that the order is medically appropriate and consistent with the Patient’s wishes, is willing to issue the order.
1.4 Effective Date. This Directive is effective on the date last signed below (the “Effective Date”).
1.5 Governing Law. This Directive is governed exclusively by the laws of the State of Indiana applicable to medical directives and out-of-hospital DNR orders.
2. DEFINITIONS
For purposes of this Directive, capitalized terms have the meanings set forth below.
“DNR Order” means the standing medical order issued under Section 3 directing that no CPR, defibrillation, intubation, or advanced cardiac life support be initiated in the event of cardiopulmonary arrest.
“EMS Personnel” means emergency medical technicians, paramedics, first responders, and other out-of-hospital health-care providers operating under Indiana emergency medical services regulations.
“Good Faith” means honesty in fact and the reasonable belief that one’s action is legally authorized and medically appropriate under the circumstances.
“Health-Care Provider” means any individual or entity licensed, certified, or otherwise authorized to provide medical care or emergency medical services in Indiana.
“Revocation” has the meaning given in Section 3.7.
3. OPERATIVE PROVISIONS
3.1 Patient Directive. Patient (or Representative on Patient’s behalf) expressly directs that no resuscitative measures be undertaken if Patient suffers cardiopulmonary arrest outside a hospital or other inpatient setting.
3.2 Physician Order. Physician hereby issues a DNR Order consistent with the Patient Directive. Health-Care Providers acting in reliance on this Directive in Good Faith shall withhold CPR, defibrillation, advanced airway management, or administration of cardiac medications intended to restart the heart or breathing.
3.3 Permitted Interventions. Comfort-focused treatments (e.g., oxygen, pain management, bleeding control, airway suctioning) may be provided as clinically indicated.
3.4 Presentation to EMS. This Directive, a state-approved DNR form, bracelet, necklace, or other statutorily recognized identifier shall be presented to EMS Personnel at the earliest opportunity. EMS Personnel shall honor the DNR Order when presented with reasonably reliable evidence of its validity.
3.5 Form Requirements.
(a) Written Form. This Directive must:
(i) be signed by Patient (or Representative) and Physician;
(ii) be witnessed in accordance with Section 10; and
(iii) contain the statements mandated by Indiana DNR law in substantially the form provided herein.
(b) Optional Identifier. Patient may obtain and wear a state-approved DNR identification bracelet or necklace bearing the required symbol and information to facilitate EMS recognition.
3.6 Duration. Unless earlier revoked, this Directive remains in force until (i) Patient’s death, or (ii) formal revocation under Section 3.7.
3.7 Revocation.
(a) Revocation by Patient. Patient may revoke this Directive at any time by any of the following: tearing, burning, or otherwise destroying the document; manifesting oral or written intent to revoke; or removing a DNR bracelet.
(b) Revocation by Representative. A Representative may revoke only if authorized under the instrument granting representative authority.
(c) Notice of Revocation. To be effective, revocation must be communicated to Physician or any attending Health-Care Provider.
3.8 Re-Issuance. Revocation does not preclude Patient from executing a new DNR order consistent with Indiana law.
4. REPRESENTATIONS & WARRANTIES
4.1 Patient/Representative. Patient (or Representative) represents and warrants that:
(a) Patient is at least eighteen (18) years of age;
(b) Patient understands the nature and consequences of a DNR order; and
(c) The Directive is executed voluntarily and without duress or undue influence.
4.2 Physician. Physician represents and warrants that:
(a) Physician is duly licensed to practice medicine in Indiana;
(b) Physician has explained the medical implications of a DNR order to Patient or Representative; and
(c) Physician believes, in Good Faith, that the order is medically appropriate.
5. COVENANTS & RESTRICTIONS
5.1 Patient Information Obligation. Patient (or Representative) shall:
(a) Inform family members and Health-Care Providers of this Directive’s existence;
(b) Carry or display a recognized DNR identifier when feasible.
5.2 Physician Covenant. Physician shall promptly enter the DNR Order into Patient’s medical record and take reasonable steps to inform facilities and EMS agencies involved in Patient’s care.
6. DEFAULT & REMEDIES
6.1 Events of Default. A “Default” occurs if any party materially breaches Section 3 or Section 5.
6.2 Cure. Upon written notice of Default, the breaching party shall take reasonable steps to cure within a commercially reasonable time or, if impossible, within the minimum time necessary under the circumstances.
6.3 Remedies.
(a) Equitable Relief. Because monetary damages are inadequate, the parties acknowledge that injunctive or declaratory relief may be sought to enforce this Directive.
(b) No Penalty to Health-Care Providers. A Health-Care Provider acting in Good Faith reliance on this Directive shall not be liable for civil damages or subject to disciplinary action for withholding resuscitation.
[// GUIDANCE: Sections 6.1–6.3 anticipate disputes such as unauthorized resuscitation or refusal to honor the Directive. Customize enforcement language to match client risk tolerance.]
7. RISK ALLOCATION
7.1 Indemnification – Provider Protection. Patient (and Representative) agree to indemnify and hold harmless Physician and any Health-Care Provider from and against any and all claims, liabilities, losses, or expenses (including reasonable attorneys’ fees) arising out of their Good-Faith compliance with this Directive.
7.2 Limitation of Liability – Good Faith Standard. No party shall be liable for consequential, special, or punitive damages so long as that party acts in Good Faith pursuant to this Directive and applicable law.
7.3 Force Majeure. A party is excused from performance if compliance is prevented by circumstances beyond its reasonable control, including but not limited to acts of God, catastrophic disasters, or sudden changes in law rendering performance illegal.
8. DISPUTE RESOLUTION
8.1 Governing Law. Indiana law governs all matters arising under or related to this Directive.
8.2 Venue. Any judicial proceeding shall be brought in a court of competent jurisdiction located in [COUNTY], Indiana.
8.3 Arbitration; Jury Waiver. Not applicable.
8.4 Injunctive Relief. The right to seek injunctive or declaratory relief to enforce this Directive is preserved notwithstanding Section 8.3.
9. GENERAL PROVISIONS
9.1 Amendment. This Directive may be amended only by a new written instrument 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 remainder shall be enforced to the fullest extent permitted by law.
9.4 Integration. This Directive constitutes the entire agreement and supersedes all prior discussions relating to the subject matter hereof.
9.5 Electronic Signatures. Electronic or digital signatures and counterparts are permitted to the fullest extent allowed by Indiana law.
10. EXECUTION BLOCK
[// GUIDANCE: Indiana requires TWO adult witnesses who satisfy statutory eligibility criteria (e.g., not the attending physician or an EMS provider who will rely on the order). Customize witness qualifiers as needed.]
Executed as of the Effective Date.
10.1 Patient / Representative
Signature of Patient: ___
Printed Name: [PATIENT NAME]
Date: _____
☐ Patient signs personally ☐ Representative signs on Patient’s behalf
If Representative signs:
Signature of Representative: ___
Printed Name: [REPRESENTATIVE NAME]
Authority (attach documentation): _
Date: _____
10.2 Attending Physician
Signature: ____
Printed Name: [PHYSICIAN NAME], M.D./D.O.
Indiana License No.: [NUMBER]
Date: _____
10.3 Witnesses
I declare under penalty of perjury that (i) the individual who signed above is personally known to me or has provided satisfactory proof of identity, (ii) in my presence the individual voluntarily executed this Directive, and (iii) I am at least 18 years old and am not disqualified from acting as a witness under Indiana law.
Witness #1:
Signature: ____
Printed Name: ____
Date: ________
Witness #2:
Signature: ____
Printed Name: ____
Date: ________
[OPTIONAL NOTARIZATION – use if local practice or facility policy mandates notarization]
State of Indiana )
) SS:
County of __)
Subscribed and sworn before me on _, 20, by the individual(s) whose name(s) appear above.
Notary Public Signature
My Commission Expires: _
County of Residence: ___
[// GUIDANCE: FILE COPIES—Provide copies to (1) Patient, (2) Representative, (3) Physician, (4) primary Health-Care facility, and (5) local EMS agency where feasible.]