KENTUCKY DO NOT RESUSCITATE (DNR) DIRECTIVE

(a/k/a “Kentucky EMS-Recognized DNR Order”)

[// GUIDANCE: This template merges (i) Kentucky’s statutory Living Will / EMS-DNR requirements, (ii) best-practice defensive drafting, and (iii) the section architecture requested. Delete inapplicable bracketed text and complete all placeholders before execution.]

TABLE OF CONTENTS

1. DOCUMENT HEADER
2. DEFINITIONS
3. OPERATIVE PROVISIONS
4. REPRESENTATIONS & WARRANTIES
5. COVENANTS & RESTRICTIONS
6. DEFAULT & REMEDIES (Reserved – not customarily used in DNR)
7. RISK ALLOCATION
8. DISPUTE RESOLUTION
9. GENERAL PROVISIONS
10. EXECUTION BLOCK

1. DOCUMENT HEADER

1.1 Title.
 KENTUCKY DO NOT RESUSCITATE (DNR) DIRECTIVE AND EMS ORDER

1.2 Parties.
 a. “Patient” – [NAME], DOB [MM/DD/YYYY], last four SSN [####]
 b. “Health-Care Provider(s)” – includes any physician, advanced practice registered nurse (“APRN”), hospital, long-term-care facility, Emergency Medical Services (“EMS”) personnel, or other licensed provider acting within Kentucky.

1.3 Recitals.
 WHEREAS, Patient is competent, of sound mind, and desires to control future health-care decisions;
 WHEREAS, Kentucky state_healthcare_law authorizes a competent adult (or authorized surrogate) to execute a directive instructing providers not to perform cardiopulmonary resuscitation (“CPR”) in the event of cardiac or respiratory arrest;
 WHEREAS, Patient seeks EMS recognition of this directive in all out-of-hospital settings;
 NOW, THEREFORE, Patient executes this Directive as a present exercise of Patient’s right to refuse life-prolonging treatment.

1.4 Effective Date; Jurisdiction.
 This Directive becomes effective on the date of the last signature below and shall be governed by the laws of the Commonwealth of Kentucky.

2. DEFINITIONS

“Advance Directive” – any written statement by which a person states choices for medical treatment or designates a surrogate to make decisions.

“Cardiopulmonary Resuscitation” or “CPR” – external chest compressions, defibrillation, ventilation, or administration of medications to restore cardiac or pulmonary function.

“Do Not Resuscitate Order” or “DNR Order” – a medical order, executed in compliance with Kentucky law, directing that CPR not be attempted if the Patient’s heart stops or Patient stops breathing.

“EMS” – Kentucky Emergency Medical Services personnel certified or licensed under KRS Chapter 311A.

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

“Qualified Witness” – an adult ≥18 years, not related to Patient by blood, marriage, or adoption, not entitled to Patient’s estate, and not financially responsible for Patient’s medical care.

“Surrogate” – the person authorized to make health-care decisions on Patient’s behalf under KRS Chapter 311 when Patient lacks decisional capacity.

3. OPERATIVE PROVISIONS

3.1 Directive Not to Attempt Resuscitation.
 Patient hereby directs that no CPR be initiated or continued if Patient experiences cardiac arrest, respiratory arrest, or a combination thereof.

3.2 Scope and Settings.
 a. This Directive applies in all health-care facilities, outpatient clinics, and during transport or care by EMS.
 b. For EMS recognition, this Directive shall be printed on florescent-lime-green card stock or otherwise displayed in accordance with Kentucky Board of Emergency Medical Services (“KBEMS”) protocols.

3.3 Authorization to Issue Medical Order.
 Patient requests and authorizes the undersigned physician/APRN to issue the corresponding Medical Order for DNR contemporaneously with execution of this Directive.

3.4 Identification Accessories.
 Patient (or Surrogate) may obtain and wear a DNR bracelet, necklace, or anklet bearing the KBEMS-approved emblem. Presentation of any such accessory creates a rebuttable presumption that a valid DNR Order exists.

3.5 Revocation.
 a. Patient may revoke this Directive at any time by:
  (i) verbally expressing intent to rescind;
  (ii) destroying this document and any DNR identification; or
  (iii) executing a subsequent directive inconsistent herewith.
 b. Upon revocation, Patient (or Surrogate) shall promptly notify Health-Care Provider(s) and EMS.

3.6 Conditions Precedent.
 This Directive shall not be implemented unless all of the following conditions are met:
  (i) The Patient experiences cardiac or respiratory arrest;
  (ii) There is a valid, unrevoked DNR Order signed by a Kentucky-licensed physician/APRN; and
  (iii) EMS or facility staff have verified the presence of the lime-green form or approved identification.

[// GUIDANCE: Insert additional clinical qualifiers (e.g., terminal illness, specific diagnoses) if desired.]

4. REPRESENTATIONS & WARRANTIES

4.1 Patient Representations.
 a. Patient is at least 18 years of age (or an emancipated minor) and of sound mind.
 b. Patient is executing this Directive voluntarily, without undue influence or duress.
 c. Patient understands the full medical consequences of refusing CPR.

4.2 Physician/APRN Representations.
 a. The undersigned has explained to Patient (or Surrogate) the nature of CPR and the likely medical outcomes.
 b. The undersigned believes, in good faith, that Patient comprehends the information provided.

4.3 Survival.
 These representations shall survive the Patient’s incapacity and remain binding on all Health-Care Provider(s) unless and until this Directive is lawfully revoked.

5. COVENANTS & RESTRICTIONS

5.1 Patient Covenants.
 a. Patient (or Surrogate) shall maintain the original lime-green form in an easily accessible location.
 b. Patient shall present a copy of this Directive upon admission to any health-care facility.

5.2 Provider Covenant.
 Health-Care Provider(s) shall honor this Directive in accordance with Kentucky law and established clinical protocols, subject to Section 3.6.

6. DEFAULT & REMEDIES (Reserved)

[// GUIDANCE: Traditional “default” concepts are inapposite to a medical directive; section reserved to preserve numbering coherence.]

7. RISK ALLOCATION

7.1 Indemnification of Health-Care Provider(s).
 Patient (and Patient’s estate) shall defend, indemnify, and hold harmless any Health-Care Provider acting in good faith reliance upon this Directive against any claim, liability, damage, or expense (including reasonable attorneys’ fees) arising from compliance herewith.

7.2 Limitation of Liability.
 No Health-Care Provider shall be liable in either civil or criminal actions for withholding CPR in accordance with a valid, unrevoked Directive or DNR Order executed under Kentucky law, provided the Provider acts in good faith.

7.3 Insurance.
 Nothing herein shall be construed to diminish or impair any professional liability insurance coverage held by Health-Care Provider(s).

7.4 Force Majeure.
 Performance of this Directive may be excused when prevented by circumstances beyond reasonable control, including but not limited to disasters that preclude verification of the Directive.

8. DISPUTE RESOLUTION

8.1 Governing Law.
 This Directive shall be governed by, and construed in accordance with, the laws of the Commonwealth of Kentucky, without regard to its conflict-of-laws principles.

8.2 Injunctive Relief.
 Because the subject matter involves personal bodily integrity and potentially irreversible medical actions, the parties acknowledge that injunctive or declaratory relief may be the only adequate remedy for disputes concerning enforcement or revocation.

8.3 Arbitration / Jury Waiver / Forum Selection.
 Not applicable under the parties’ election and as reflected in the metadata.

9. GENERAL PROVISIONS

9.1 Amendment and Waiver.
 Only Patient (or authorized Surrogate while Patient is incapacitated) may amend or waive any provision herein, and then only by an instrument in writing signed, dated, and witnessed/notarized in accordance with Section 10.

9.2 Assignment.
 This Directive is personal to Patient and may not be assigned or delegated.

9.3 Successors and Assigns.
 The benefits and protections of this Directive shall inure to Patient’s heirs, executors, administrators, and legal representatives, and shall bind Health-Care Provider(s) and their respective agents, employees, and affiliates.

9.4 Severability.
 If any provision is determined unenforceable, the remainder shall be interpreted to best effectuate the Patient’s intent consistent with Kentucky law.

9.5 Integration.
 This Directive, together with the contemporaneously issued medical order, constitutes the entire agreement regarding resuscitative efforts and supersedes any prior inconsistent directives.

9.6 Counterparts & Electronic Signatures.
 This Directive may be executed in any number of counterparts (including electronic or facsimile signatures), each of which shall be deemed an original.

10. EXECUTION BLOCK

[// GUIDANCE: Kentucky permits EITHER two Qualified Witnesses OR a Notary acknowledgment. EMS typically requires the original lime-green form bearing wet signatures.]

10.1 Patient / Surrogate Signature

Relationship to Patient (if Surrogate): ________

10.2 Physician / APRN Signature

[// GUIDANCE: Physician/APRN should simultaneously issue a formal “Medical Order for DNR” on required KBEMS form.]

10.3 Witnesses (use this subsection OR Notary subsection 10.4)

Witness Qualification Affirmation: Each witness affirms under penalty of perjury that he/she is (i) ≥18 years old, (ii) not related to Patient, (iii) not entitled to Patient’s estate, and (iv) not responsible for Patient’s medical bills.

10.4 Notary Public

State of Kentucky  County of ____

Subscribed, sworn to, and acknowledged before me this _ day of __, 20____ by [PATIENT/SURROGATE NAME].

Notary Public Signature: ____
Printed Name: _____
Commission Expires: ________
Notary Seal:

[// GUIDANCE:

1. Provide copies to: (a) Patient’s medical file; (b) Surrogate; (c) Primary Care Physician; (d) EMS-accessible location in residence.
2. Recommend entering the Directive into the Kentucky e-registries (if available) or facility electronic health record.
3. Confirm facility policy on color-coded wristbands to avoid contradictory code-status orders.
   ]