Medical Directive - DNR

MARYLAND DO NOT RESUSCITATE (DNR) MEDICAL DIRECTIVE

(Advance Directive & EMS/DNR Order)

Effective Date: [ EFFECTIVE DATE]
Governing Law: Maryland Health–General Article Title 5 & COMAR 10.01.21

TABLE OF CONTENTS

1. Document Header
2. Definitions
3. Operative Provisions
4. Representations & Warranties
5. Covenants & Restrictions
6. Default & Remedies
7. Risk Allocation
8. Dispute Resolution (Intentionally Omitted)
9. General Provisions
10. Execution Block

1. DOCUMENT HEADER

This Maryland Do Not Resuscitate Medical Directive (this “Directive”) is made by [PATIENT NAME], date of birth [DOB] (“Patient”), and, if applicable, [AUTHORIZED DECISION MAKER NAME] (“Authorized Decision Maker”), in consultation with [HEALTH CARE PROVIDER NAME & CREDENTIALS] (the “Attending Provider”).

Recitals
A. Maryland law recognizes an individual’s right to forego cardiopulmonary resuscitation (“CPR”) and related life-sustaining treatments. Md. Code Ann., Health-Gen. § 5-602.
B. COMAR 10.01.21 establishes the only EMS-recognizable DNR order in Maryland.
C. Patient desires that no resuscitative efforts be initiated in the event of cardiac or respiratory arrest, subject to the terms herein.

Consideration: Mutual promises contained herein and the Patient’s directive to health-care providers.

2. DEFINITIONS

Advance Directive – a written instruction recognized under Md. Code Ann., Health-Gen. § 5-601 et seq.
Attending Provider – the physician, nurse practitioner, or physician assistant with primary responsibility for Patient’s care.
Cardiopulmonary Resuscitation (CPR) – chest compressions, artificial ventilation, defibrillation, cardiac drugs, or other measures to restore cardiac or respiratory function.
Comfort Care – treatment to relieve pain or suffering without attempting to cure.
COMAR – Code of Maryland Regulations.
EMS – Maryland emergency medical services personnel.
Good Faith – honesty in fact in the conduct of the transaction; the standard for provider immunity under Md. Code Ann., Health-Gen. § 5-609.
MOLST – Maryland Medical Orders for Life-Sustaining Treatment.
Qualified Witness – a person meeting the requirements of Md. Code Ann., Health-Gen. § 5-602(c).
Revocation – a written or oral expression by Patient rescinding this Directive.

3. OPERATIVE PROVISIONS

3.1 DNR Instruction. In the event of cardiac or respiratory arrest, no CPR shall be initiated.
3.2 Scope of Non-Resuscitation. The prohibition includes, without limitation, chest compressions, defibrillation, advanced airway management, artificial ventilation, and administration of resuscitative medications.
3.3 Comfort Care. Patient does / does not [SELECT ONE] consent to comfort-focused treatments (e.g., oxygen, analgesia, anxiolytics) consistent with palliative care standards.
3.4 EMS Recognition & Order. Pursuant to COMAR 10.01.21, § .04:
 (a) This Directive constitutes a valid EMS/DNR Order when signed by the Attending Provider in § 10 and contains either:
  • DNR-A: Comfort care only or
  • DNR-B: Limited additional interventions short of intubation & CPR.
 (b) EMS personnel shall honor this Order in the field.
3.5 Identification. Patient will wear [CHECK ONE] ☐ Maryland EMS DNR Bracelet ☐ Neck Medallion ☐ Wallet Card referencing this Directive.
3.6 Revocation. Patient may revoke at any time by:
 (i) destroying this Directive;
 (ii) oral statement to health-care personnel; or
 (iii) executing a new advance directive.
3.7 Copies; Electronic Versions. Photocopies, facsimiles, and electronically transmitted copies bearing signatures are as effective as originals.

4. REPRESENTATIONS & WARRANTIES

4.1 Patient/Authorized Decision Maker represents:
 (a) Capacity. Patient has capacity, or Authorized Decision Maker is duly appointed under a valid power of attorney or by statute.
 (b) Voluntariness. Execution is voluntary, free of duress or undue influence.
4.2 Attending Provider represents:
 (a) Compliance. Provider has explained medical consequences; Patient (or Authorized Decision Maker) demonstrated understanding.
 (b) Authority. Provider holds an active Maryland license and is authorized to issue EMS/DNR Orders under COMAR 10.01.21.§ .03.
4.3 Witnesses represent:
 (a) Qualification. Each is at least 18 and a Qualified Witness; at least one witness is NOT (i) a relative by blood, marriage, or adoption, (ii) entitled to any portion of Patient’s estate, (iii) financially responsible for Patient’s care, or (iv) directly involved in Patient’s care.

Representations survive execution and delivery of this Directive.

5. COVENANTS & RESTRICTIONS

5.1 Patient covenants to provide copies of this Directive to:
 (a) Health-care agent(s);
 (b) Primary care provider;
 (c) Any health-care facility upon admission.
5.2 Provider covenants to:
 (a) Place this Directive in the permanent medical record;
 (b) Communicate the Order to on-call and ancillary staff;
 (c) Re-confirm validity annually or upon material change in Patient’s medical condition.
5.3 Facilities covenant to honor the Directive consistent with Md. Code Ann., Health-Gen. § 5-613.
5.4 Notice & Cure. Any party uncertain of validity shall promptly notify the Attending Provider; Provider shall cure uncertainty within 4 hours or escalate per facility policy.

6. DEFAULT & REMEDIES

6.1 Event of Default. Initiation of CPR contrary to this Directive or refusal by a provider to honor it absent statutory exception.
6.2 Remedies.
 (a) Primary Relief. Injunctive and declaratory relief to enforce Patient’s rights.
 (b) Attorneys’ Fees. Reasonable fees to prevailing party enforcing this Directive.
 (c) Limitations. No monetary damages against providers acting in Good Faith.

7. RISK ALLOCATION

7.1 Indemnification – Provider Protection. Patient (and Patient’s estate) indemnifies and holds harmless any Health-care Provider or Facility for acts or omissions in Good Faith reliance on this Directive, except for gross negligence or willful misconduct.
7.2 Limitation of Liability. In no event shall any indemnified party be liable for consequential, punitive, or exemplary damages arising from Good Faith compliance.
7.3 Insurance. Providers remain subject to professional liability insurance requirements under Maryland law.
7.4 Force Majeure. Non-performance is excused where compliance is impossible due to acts of God, disaster, or circumstances outside the provider’s reasonable control; providers must nevertheless render best efforts consistent with patient safety and legal requirements.

8. DISPUTE RESOLUTION

Intentionally Omitted – Not applicable to this Directive.

9. GENERAL PROVISIONS

9.1 Amendment. Patient may amend this Directive only by a subsequent signed writing complying with Maryland law.
9.2 Assignment. Rights and duties hereunder are personal to Patient and may not be assigned.
9.3 Successors. Binding upon and inure to the benefit of Patient’s heirs, executors, administrators, and representatives.
9.4 Severability. If any provision is held unenforceable, the remainder shall be given full effect to the maximum extent permitted.
9.5 Entire Agreement. This Directive constitutes the complete statement of Patient’s DNR instructions and supersedes all prior inconsistent writings.
9.6 Counterparts; Electronic Signatures. May be executed in multiple counterparts and by electronic signature under Md. Code Ann., Com. Law § 21-101 et seq.

10. EXECUTION BLOCK

10.1 PATIENT OR AUTHORIZED DECISION MAKER

Signature: _________________________________ Date: __________
Printed Name: ______________________________ Relationship (if not Patient): __________

10.2 WITNESSES

Witness #1 Signature: ________________________ Date: __________
Printed Name & Address: _____________________________________

Witness #2 Signature: ________________________ Date: __________
Printed Name & Address: _____________________________________

10.3 ATTENDING PROVIDER – EMS/DNR ORDER

☐ DNR-A (Comfort Care Only)  ☐ DNR-B (Limited Additional Interventions)

I hereby issue an EMS/DNR Order consistent with § 3.4.

Provider Signature: _________________________ Date/Time: __________
Printed Name & Maryland License No.: __________________________________
Facility / Practice: _________________________________________________
Provider Phone: ______________________

NOTARY ACKNOWLEDGMENT (OPTIONAL)
State of Maryland, County of _____________:
Subscribed and sworn before me on ____________, 20__, by ____________________.
Notary Public: __________________________ My Commission Expires: __________

© [YEAR] [LAW FIRM NAME]. All rights reserved.