Medical Directive - DNR

KANSAS DO NOT RESUSCITATE (“DNR”) DIRECTIVE

(Out-of-Hospital Use – K.S.A. 65-4941 et seq.)

TABLE OF CONTENTS

1. Document Header.............................................................1
2. Definitions...................................................................2
3. Operative Provisions (Directive & Authorization).............................3
4. Representations & Warranties................................................4
5. Covenants & Restrictions....................................................4
6. Revocation; Amendment; Replacement...........................................5
7. Risk Allocation & Provider Protection.......................................5
8. Governing Law & Dispute Matters.............................................6
9. General Provisions..........................................................6
10. Execution Block (Signatures, Witnesses, Notary)............................7

1. DOCUMENT HEADER

1.1 Title. Kansas Do-Not-Resuscitate (“DNR”) Directive — Out-of-Hospital.

1.2 Declarant. [FULL LEGAL NAME OF PATIENT] (“Declarant”), date of birth [MM/DD/YYYY], residing at [ADDRESS].

1.3 Effective Date. This Directive becomes effective immediately upon the later of the Declarant’s signature or, if required, the date of acknowledgment before a notary public.

1.4 Purpose & Statutory Authority. Declarant issues this Directive pursuant to the Kansas Do-Not-Resuscitate Act, K.S.A. 65-4941 et seq., to direct health-care providers, emergency medical services (“EMS”) personnel, and others to withhold cardiopulmonary resuscitation (“CPR”) in the event of Declarant’s cardiopulmonary arrest outside a hospital or licensed health-care facility.

2. DEFINITIONS

For purposes of this Directive, capitalized terms have the meanings set forth below. (Alphabetical)

“Cardiopulmonary Arrest” means the cessation of spontaneous respiration and circulation.

“Cardiopulmonary Resuscitation” or “CPR” means chest compressions, artificial ventilation, airway management, defibrillation, administration of cardiac drugs, or any other medical intervention to restart the heart or breathing.

“Declarant” means the competent adult executing this Directive.

“Directive” means this Kansas Do-Not-Resuscitate Directive.

“EMS Personnel” means first responders, emergency medical technicians, paramedics, and ambulance attendants licensed or certified under Kansas law.

“Good Faith” means honesty in fact in the conduct of the transaction concerned.

“Physician” means a person licensed to practice medicine and surgery in the State of Kansas under K.S.A. 65-2801 et seq.

“Qualified Witness” has the meaning set forth in Section 10.3(b) of this Directive and K.S.A. 65-4944.

3. OPERATIVE PROVISIONS (DIRECTIVE & AUTHORIZATION)

3.1 DNR Instruction. IF I EXPERIENCE CARDIOPULMONARY ARREST, DO NOT PERFORM CARDIOPULMONARY RESUSCITATION OR OTHER LIFE-SUSTAINING RESUSCITATIVE MEASURES. I direct that no chest compressions, defibrillation, advanced airway management, artificial ventilation, cardiac stimulant drugs, or similar attempts to restart my heart or breathing be initiated or continued.

3.2 Limited Interventions Permitted. This Directive does not prohibit:
(a) airway suctioning to maintain comfort;
(b) administration of oxygen or other measures solely to provide comfort;
(c) relief of pain; or
(d) other palliative care consistent with accepted medical standards.

3.3 Authorization to Health-Care Providers & EMS.
(a) Declarant authorizes and requests all physicians, nurses, EMS personnel, and health-care facilities to honor this Directive and to act in reliance hereon.
(b) Declarant further authorizes EMS personnel to provide comfort measures and to transfer Declarant to an appropriate facility without performing CPR.

3.4 Distribution; Visibility. Declarant understands that prompt recognition by EMS requires conspicuous evidence of this Directive and agrees to:
(a) keep the original on the person or in an easily accessible location;
(b) present copies to family members, caregivers, and healthcare providers; and
(c) consider wearing a DNR bracelet/necklace approved under Kansas regulations.

4. REPRESENTATIONS & WARRANTIES

4.1 Capacity & Voluntariness. Declarant affirms that:
(a) Declarant is at least 18 years of age, of sound mind, and acting voluntarily, free of duress, fraud, or undue influence; and
(b) Declarant has discussed or been offered the opportunity to discuss this decision with a licensed physician.

4.2 Understanding of Consequences. Declarant understands the nature and consequences of withholding CPR, including the possibility of death.

4.3 Accuracy of Information. All personal information supplied herein is complete and accurate to the best of Declarant’s knowledge.

5. COVENANTS & RESTRICTIONS

5.1 Notification Obligation. Declarant covenants to notify attending physicians and facilities of the existence of this Directive upon admission or transfer.

5.2 No Contradictory Instructions. Declarant shall not knowingly execute another document that conflicts with this Directive without formally revoking or amending this Directive in accordance with Section 6.

6. REVOCATION; AMENDMENT; REPLACEMENT

6.1 Revocation by Declarant. Declarant may revoke this Directive at any time by any of the methods permitted under K.S.A. 65-4945, including but not limited to:
(a) a signed, dated writing expressing intent to revoke;
(b) destroying or defacing the original Directive; or
(c) an oral statement of revocation in the presence of a health-care provider or witness.

6.2 Automatic Revocation. This Directive is deemed revoked if the Declarant is known to be pregnant and the fetus could be born alive with continued medical treatment, consistent with K.S.A. 65-4944(b).

6.3 Amendment or Replacement. Any amendment or replacement must comply with statutory form requirements then in effect and must be executed with the same formalities as the original Directive.

7. RISK ALLOCATION & PROVIDER PROTECTION

7.1 Provider Immunity. Health-care providers and EMS personnel who, in Good Faith, act pursuant to this Directive or disregard it upon reasonable determination that it has been revoked, are entitled to the civil and criminal immunity afforded by K.S.A. 65-4946.

7.2 Indemnification. Declarant discharges and agrees to hold harmless any provider or facility that in Good Faith honors this Directive, except for acts of gross negligence or willful misconduct.

7.3 Limitation of Liability. No provider shall be liable for damages in excess of those permitted under applicable Kansas law when acting in reliance upon this Directive in Good Faith.

8. GOVERNING LAW & DISPUTE MATTERS

8.1 Governing Law. This Directive and any disputes arising hereunder shall be governed exclusively by the laws of the State of Kansas without regard to conflict-of-law principles.

8.2 Forum Selection; Arbitration; Jury Waiver. Not applicable.

8.3 Injunctive Relief. Any court of competent jurisdiction sitting in Kansas may issue injunctive relief to enforce or prevent the violation of this Directive.

9. GENERAL PROVISIONS

9.1 Severability. If any provision of this Directive is held invalid or unenforceable, the remaining provisions shall remain in full force to the maximum extent permitted by law.

9.2 Entire Directive. This document constitutes the Declarant’s complete DNR directive and supersedes all prior DNR directives, whether oral or written.

9.3 Copies. Photocopies, facsimiles, and electronically-transmitted copies of this Directive shall have the same legal effect as the original.

9.4 Counterparts. This Directive may be executed in counterparts, each of which shall be deemed an original.

10. EXECUTION BLOCK

10.1 Declarant Signature

I, the Declarant, sign my name to this Kansas Do-Not-Resuscitate Directive on the date set forth below and affirm the truth of every statement herein.

Signature: _______________________________
Printed Name: ____________________________
Date: _______________, 20___

10.2 Physician Confirmation (Optional but strongly recommended for EMS recognition)

I am the attending or primary care physician for the above-named Declarant. I have discussed the medical implications of a Do-Not-Resuscitate order, and in my medical judgment the Declarant is competent to execute this Directive.

Physician Signature: ______________________ Date: _____________
Printed Name: ____________________________ KS License No.: ______
Practice Address: _____________________________________________

10.3 Witnesses or Notary (choose ONE)

(a) Two Qualified Witnesses

We declare that we are at least 18 years of age, are not disqualified by K.S.A. 65-4944, and witnessed the Declarant sign or acknowledge this Directive.

(b) Notary Public Acknowledgment

State of Kansas )
County of ______ ) ss.

This instrument was acknowledged before me on ____________, 20___, by ______________________________ [Name of Declarant].

(Notary Seal)

________________________________________________
Notary Public
My commission expires: _________________________

10.4 EMS RECOGNITION ADVISORY

This form is intended for out-of-hospital use. EMS personnel may require the original form or an approved DNR bracelet/necklace to honor the Directive (K.S.A. 65-4947). Declarant should maintain visibility of this Directive at all times.