LOUISIANA DO NOT RESUSCITATE (“DNR”) DIRECTIVE
(Comprehensive Medical Directive Compliant with Louisiana Requirements and EMS Protocols)
TABLE OF CONTENTS
- Document Header
- Definitions
- Operative Provisions (Directive Instructions)
- Representations & Warranties
- Covenants & Restrictions
- Revocation & Remedies
- Risk Allocation
- Governing Law & Dispute Resolution
- General Provisions
- Execution Block
- Annex A – EMS Recognition Guidance (Informational)
1. DOCUMENT HEADER
1.1 Title.
LOUISIANA DO NOT RESUSCITATE (“DNR”) DIRECTIVE
1.2 Parties.
(a) Patient: [PATIENT LEGAL NAME] (“Patient”)
(b) Authorized Representative (if any): [REPRESENTATIVE NAME] (“Representative”)
(c) Attending Physician: [PHYSICIAN NAME, LICENSE NO.] (“Physician”)
(d) Covered Health-Care Providers and Facilities: [INSERT, e.g., HOSPITAL NAME, EMS AGENCY] (collectively, “Providers”)
1.3 Effective Date.
This Directive is effective on the earlier of (i) the date executed by the Patient or (ii) the date executed by the Representative acting pursuant to valid authority (the “Effective Date”).
1.4 Governing Law.
This Directive is governed by and shall be construed in accordance with the health-care laws of the State of Louisiana (“State Health-Care Law”).
1.5 Purpose & Consideration.
The Patient, desiring to exercise the fundamental right to determine medical treatment, issues this Directive to instruct all Providers to withhold cardiopulmonary resuscitation (“CPR”) and other specified resuscitative measures in the event of cardiopulmonary arrest.
2. DEFINITIONS
For ease of reference, the following capitalized terms have the meanings set forth below. All references to Sections are to sections of this Directive unless otherwise indicated.
“Advance Directive” – A written instruction, recognized under State Health-Care Law, relating to the provision of health-care when the Patient lacks capacity.
“Authorized Representative” – A person authorized under State Health-Care Law to make health-care decisions for the Patient, including but not limited to a duly-appointed health-care agent, tutor, curator, or court-appointed guardian.
“Cardiopulmonary Arrest” – The absence of spontaneous respiratory and circulatory function.
“CPR” – All medical interventions intended to restore breathing or heart function, including chest compressions, defibrillation, intubation, mechanical ventilation, vasoactive drugs, and similar measures.
“DNR Order” – A medical order, duly executed in compliance with State Health-Care Law and EMS protocols, directing Providers not to initiate CPR if the Patient experiences Cardiopulmonary Arrest.
“EMS Personnel” – Licensed emergency medical technicians, paramedics, or other first responders operating under Louisiana emergency medical services protocols.
“Good Faith” – Honesty in fact and the observance of reasonable medical standards prevailing at the time of treatment.
“Physician” – The Attending Physician who issues the medical order component of this Directive.
“Providers” – Collectively, the Physician, health-care professionals, hospitals, long-term care facilities, hospice programs, EMS Personnel, and any other persons or entities subject to the Patient’s health-care instructions.
“Witness” – An individual who meets the qualification requirements set out in Section 10.3.
3. OPERATIVE PROVISIONS (DIRECTIVE INSTRUCTIONS)
3.1 DNR Instruction.
Upon the occurrence of Cardiopulmonary Arrest and presentation of a valid DNR Order as set forth herein, all Providers SHALL WITHHOLD CPR and SHALL NOT attempt cardioversion, intubation, positive-pressure ventilation, advanced airway placement, or administration of resuscitative drugs.
3.2 Scope of Treatment Permitted.
This Directive does not prohibit:
(a) Administration of comfort-care or palliative measures;
(b) Pain management, oxygen, suction, or other therapies intended solely for symptom relief;
(c) Treatment of reversible conditions prior to Cardiopulmonary Arrest (e.g., antibiotics, blood products) unless otherwise directed by the Patient in writing.
3.3 Physician Order Requirement.
(a) The Physician SHALL complete and sign the Louisiana‐approved DNR Order form contemporaneously with this Directive.
(b) The completed form shall be reproduced on the distinctive paper/color mandated by Louisiana Office of Public Health (“Official DNR Form”) OR be stored electronically in the Patient’s medical record in accordance with State Health-Care Law.
3.4 EMS Recognition.
A legible original, photocopy, or digital image of the Official DNR Form, or a State-recognized DNR bracelet/necklace displaying the Louisiana DNR emblem, constitutes prima facie evidence of a valid DNR Order for EMS Personnel.
3.5 Portability.
This Directive is intended to follow the Patient across all settings, including but not limited to hospitals, nursing homes, hospices, private residences, and transport by EMS Personnel.
4. REPRESENTATIONS & WARRANTIES
4.1 Capacity and Voluntariness.
The Patient represents that, as of the Effective Date, the Patient is of sound mind, at least eighteen (18) years of age or an emancipated minor, and acting voluntarily without undue influence.
4.2 Authenticity of Representative Authority.
If executed by a Representative, such Representative warrants valid authority to act and that no contrary instruction of the Patient is known to them.
4.3 Accuracy of Information.
The Patient or Representative certifies that all information contained herein is true, complete, and accurate to the best of their knowledge.
5. COVENANTS & RESTRICTIONS
5.1 Provider Obligations.
(a) Providers shall honor this Directive in Good Faith and in accordance with professional standards.
(b) Providers shall promptly document compliance or any refusal to comply in the Patient’s medical record.
5.2 Notification & Transfer.
A Provider unwilling or unable to honor the Directive shall, at the earliest feasible time, arrange for transfer of the Patient to a Provider who will comply, consistent with State Health-Care Law.
5.3 No Requirement to Provide Futile Care.
Nothing in this Directive shall compel a Provider to furnish care deemed medically futile or non-beneficial under applicable professional standards.
6. REVOCATION & REMEDIES
6.1 Revocation by Patient.
The Patient may revoke this Directive at any time verbally or in writing, or by physical destruction of the Official DNR Form, without regard to mental or physical condition.
6.2 Revocation by Representative.
A Representative may revoke only where authorized under State Health-Care Law and subject to any known contrary wishes of the Patient expressed while competent.
6.3 Effect of Revocation.
Upon revocation, Providers shall promptly record the revocation and, if feasible, retrieve or void any visible DNR identifiers (e.g., bracelet).
6.4 Remedies for Non-Compliance.
Failure by a Provider to honor this Directive may subject the Provider to professional discipline or civil liability as provided under State Health-Care Law.
7. RISK ALLOCATION
7.1 Indemnification – Provider Protection.
The Patient (and, if applicable, the Patient’s estate) agrees to indemnify and hold harmless all Providers from and against any claim, liability, loss, or expense (including reasonable attorneys’ fees) arising out of actions or omissions taken in Good Faith reliance on this Directive or the related DNR Order.
7.2 Limitation of Liability.
No Provider acting in Good Faith and in substantial compliance with this Directive shall be liable for civil damages or subject to criminal prosecution for honoring or failing to honor the DNR Order, except for gross negligence or willful misconduct.
7.3 Insurance.
[OPTIONAL] Providers shall maintain professional liability insurance in amounts required by State Health-Care Law.
7.4 Force Majeure.
Providers shall not be deemed in breach for failure to comply when compliance is impossible due to circumstances beyond reasonable control (e.g., natural disasters that prevent verification of the Directive).
8. GOVERNING LAW & DISPUTE RESOLUTION
8.1 Governing Law.
All matters arising under or relating to this Directive shall be governed by the laws of the State of Louisiana, without regard to conflict-of-law principles.
8.2 Forum Selection.
Because this is a medical directive and not a contractual matter, formal forum selection is not applicable; however, any dispute shall be brought in a court of competent jurisdiction located in Louisiana.
8.3 Injunctive Relief.
Nothing herein shall impair the right of any party to seek injunctive or other equitable relief to enforce or restrain violations of this Directive.
9. GENERAL PROVISIONS
9.1 Amendment.
This Directive may be amended only by a new written directive executed in compliance with then-applicable State Health-Care Law.
9.2 Severability.
If any provision of this Directive is held invalid or unenforceable, the remaining provisions shall remain in full force and effect to the maximum extent permitted.
9.3 Entire Directive.
This instrument, together with the Official DNR Form executed contemporaneously, constitutes the entire understanding with respect to resuscitative measures and supersedes any prior inconsistent statements.
9.4 Counterparts; Electronic Signatures.
This Directive may be executed in counterparts, each of which is deemed an original. Signatures transmitted electronically (including via secure patient portal or electronic health record) shall be deemed originals for all purposes.
10. EXECUTION BLOCK
[// GUIDANCE: Louisiana law requires TWO qualified witnesses. Notarization is optional but recommended for evidentiary clarity.]
10.1 Patient (or Authorized Representative)
Signature: ____
Name: [PRINT NAME]
Date: ________
Relationship/Authority (if Representative): [EXPLAIN]
10.2 Attending Physician
I have explained the nature and consequences of a DNR Order to the Patient/Representative and have issued a corresponding medical order.
Signature: ____
Name: [PHYSICIAN NAME, MD/DO]
License No.: ____
Date: _________
10.3 Witnesses
Each Witness must: (i) be at least 18 years old; (ii) not be related to the Patient by blood, marriage, or adoption; (iii) not be entitled to any portion of the Patient’s estate; and (iv) not be directly responsible for the Patient’s medical care or costs.
Witness #1 Signature: ____ Date: _
Print Name: ____
Witness #2 Signature: ____ Date: _
Print Name: ____
10.4 Optional Notary Acknowledgment
STATE OF LOUISIANA
PARISH OF ______
Subscribed and sworn before me on this _ day of __, 20__.
Notary Public Signature: ____
Printed Name & Notary ID: ____
My Commission Expires: _____
11. ANNEX A – EMS RECOGNITION GUIDANCE (INFORMATIONAL ONLY)
[// GUIDANCE: This annex is not a required legal component but assists practitioners in ensuring field recognition.]
A. Present one of the following to EMS Personnel:
1. Original yellow Official DNR Form;
2. Clear photocopy of the executed form;
3. Digital image accessible on a mobile device or electronic health record;
4. State-approved DNR bracelet/necklace engraved with Patient name and Physician phone number.
B. Place the Official DNR Form:
• On the refrigerator door (standard EMS retrieval location);
• In the Patient’s chart or at bedside in institutional settings;
• In a “Vial of Life” container if such program is utilized.
C. During inter-facility transfer, ensure a copy accompanies the Patient and is provided to transport personnel.
D. If the Directive is revoked, promptly:
• Remove all DNR identifiers;
• Notify EMS agency(ies) routinely serving the Patient’s residence.
[// GUIDANCE: Practitioners should verify current Louisiana Department of Health forms and EMS protocols before finalizing this Directive. Insert facility-specific policies as appropriate.]