MAINE MEDICAL DIRECTIVE – DO NOT RESUSCITATE (DNR)
[// GUIDANCE: This template is drafted to comply with Maine‐specific DNR rules, Maine EMS protocols, and general U.S. health-care directive principles. Customize all bracketed placeholders before execution. Obtain independent legal review to ensure compliance with the most current statutes, regulations, and EMS rules.]
TABLE OF CONTENTS
- Document Header
- Definitions
- Operative Provisions
- Representations & Warranties
- Covenants & Restrictions
- Default & Remedies
- Risk Allocation
- Dispute Resolution
- General Provisions
- Execution Block
- Attachments / Exhibits
1. DOCUMENT HEADER
MAINE DO NOT RESUSCITATE (DNR) MEDICAL DIRECTIVE
Effective Date: [EFFECTIVE DATE]
Parties:
• Patient: [PATIENT LEGAL NAME], residing at [ADDRESS] (“Patient”).
• Attending/Authorizing Clinician: [PHYSICIAN/APRN/PA NAME], [MEDICAL LICENSE #] (“Clinician”).
• Health-Care Proxy / Agent (if any): [AGENT NAME], pursuant to a valid Health-Care Power of Attorney dated [DATE] (“Agent”).
Recitals:
A. Patient desires to exercise the right to refuse cardiopulmonary resuscitation (“CPR”) consistent with Maine law and ethical medical practice.
B. Clinician, having verified the Patient’s decision-making capacity or Agent authority, agrees to issue medical orders effecting the Patient’s intent.
C. This Directive is intended to be honored by all licensed emergency medical services (“EMS”) providers and health-care personnel in the State of Maine.
2. DEFINITIONS
“CPR” means chest compressions, defibrillation, advanced airway management, artificial ventilation, cardiac medications administered for resuscitation, or any other resuscitative intervention intended to restore circulatory or pulmonary function.
“Directive” means this Maine Medical Directive – Do Not Resuscitate, including all Attachments/Exhibits.
“EMS Personnel” means emergency medical technicians, advanced emergency medical technicians, paramedics, and any other personnel licensed or credentialed by Maine Emergency Medical Services.
“Good Faith” means honest belief, absence of malice, and the reasonable clinical judgment of a similarly situated health-care provider under like circumstances.
“Revocation Event” has the meaning provided in Section 6.2.
3. OPERATIVE PROVISIONS
3.1 Medical Order Not to Resuscitate
(a) The Clinician hereby orders that, in the event of cardiopulmonary arrest, no CPR shall be attempted on the Patient.
(b) Comfort-focused, palliative, and pain-relief measures shall be provided unless expressly refused under a separate advance directive.
3.2 Scope of EMS Recognition
(a) EMS Personnel presented with an original or accurately reproduced copy of this Directive—or an approved Maine EMS DNR bracelet/necklace identifying the Directive—shall honor the order in accordance with Maine EMS protocols.
(b) If only a bracelet/necklace is present, EMS Personnel may proceed under the presumption of validity absent actual knowledge of revocation.
3.3 Health-Care Facility Obligations
Hospitals, nursing facilities, and other licensed providers receiving this Directive must incorporate it into the Patient’s medical record and flag the chart accordingly.
3.4 Documentation Standards
The original executed Directive shall be printed on [RECOMMENDED: distinctively colored (e.g., gold) paper] to facilitate rapid EMS identification.
3.5 Consideration
The mutual promises herein, including the Clinician’s agreement to issue medical orders and the Patient’s advance consent to comfort-care measures, constitute adequate consideration.
[// GUIDANCE: Section 3 generally tracks Maine EMS form requirements. Delete or adapt any subsection that conflicts with the latest DHS/EMS form.]
4. REPRESENTATIONS & WARRANTIES
4.1 Patient/Agent Representations
(a) Capacity or Authority. Patient affirms capacity to execute this Directive, or Agent affirms valid authority under a current Health-Care Power of Attorney.
(b) Voluntariness. Execution is voluntary, free of coercion, and informed by adequate medical counseling.
4.2 Clinician Representations
(a) Professional Judgment. Clinician has determined the Patient’s request is medically appropriate and not contraindicated by applicable standards of care.
(b) Compliance. Clinician will enter the corresponding medical order into the Patient’s chart within [24] hours of execution.
4.3 Survival
The representations and warranties in this Section survive execution and remain binding until a Revocation Event.
5. COVENANTS & RESTRICTIONS
5.1 Patient/Agent Covenants
(a) Notification. Patient or Agent shall promptly distribute copies of this Directive to relevant health-care providers and facilities.
(b) Condition Update. Patient or Agent shall inform the Clinician if the Patient’s clinical condition significantly changes or if care is transferred to another primary clinician.
5.2 Clinician Covenants
Clinician shall (i) educate facility staff regarding the Directive, and (ii) assist in filing or registering the Directive with any statewide electronic registry if established.
5.3 Restriction on Alterations
No alteration to the Directive is permitted after execution except through (i) execution of a superseding directive in accordance with Section 6.1, or (ii) formal revocation.
6. DEFAULT & REMEDIES
6.1 Superseding Directive
Execution of a subsequent, valid DNR or POLST form revokes this Directive to the extent of any conflict.
6.2 Revocation Events
This Directive is revoked upon the earliest of:
(a) Patient’s express verbal or written revocation communicated to any health-care provider or EMS Personnel;
(b) Physical destruction or defacement of the original Directive by the Patient or Agent;
(c) Execution of a superseding Directive under Section 6.1.
6.3 Notice of Revocation
Upon a Revocation Event, the party becoming aware thereof shall use reasonable efforts to notify (i) the Clinician, (ii) all known holders of the Directive, and (iii) EMS dispatch if an emergency call is in progress.
6.4 Remedies
(a) Specific Performance. Because damages are inadequate, parties acknowledge that specific performance or injunctive relief may be the appropriate remedy to enforce or prevent violation of the Directive.
(b) Attorneys’ Fees. In any action to enforce or revoke this Directive, the prevailing party is entitled to reasonable attorneys’ fees and costs.
7. RISK ALLOCATION
7.1 Indemnification (Provider Protection)
Patient (and the Patient’s estate) shall indemnify, defend, and hold harmless the Clinician, EMS Personnel, and all other health-care providers who honor this Directive in Good Faith from any civil liability, damages, costs, or expenses arising out of compliance with this Directive, except for gross negligence or willful misconduct.
7.2 Limitation of Liability (Good-Faith Standard)
No Clinician or EMS Personnel acting in Good Faith reliance on this Directive shall be liable for any act or omission consistent with its terms.
7.3 Insurance
[OPTIONAL] Patient represents that any applicable health-care or long-term-care insurance policy permits the use of DNR directives and does not prohibit indemnification under Section 7.1.
7.4 Force Majeure
Performance delays caused by unavoidable EMS operational constraints (e.g., multi-casualty incidents) shall not be deemed non-compliance if personnel make Good-Faith efforts to honor the Directive.
8. DISPUTE RESOLUTION
8.1 Governing Law
This Directive shall be governed by and construed in accordance with the laws of the State of Maine without regard to its conflict-of-laws principles.
8.2 Forum Selection
Because this is a medical directive rather than a commercial contract, formal litigation is rarely appropriate. Any dispute arising hereunder should first be addressed through an ethics consultation or health-care mediation before resorting to judicial proceedings.
8.3 Jury Trial Waiver; Arbitration
Not applicable.
8.4 Injunctive Relief Preservation
Nothing in this Section limits any party’s right to seek immediate injunctive or declaratory relief to enforce or clarify the Directive.
9. GENERAL PROVISIONS
9.1 Amendment and Waiver
No amendment or waiver of any provision of this Directive is effective unless set forth in a written instrument executed with the same formalities as this Directive.
9.2 Assignment; Delegation
Rights and obligations under this Directive are personal to the Patient and may not be assigned, except that the Agent (if any) may act on the Patient’s behalf as permitted by law.
9.3 Severability
If any provision is held unenforceable, the remaining provisions remain in full force, and the invalid provision shall be reformed to the minimum extent necessary to effectuate the Patient’s intent.
9.4 Entire Agreement
This Directive, together with any referenced attachments, constitutes the entire agreement concerning the withholding of resuscitative measures and supersedes any prior inconsistent statements.
9.5 Electronic Signatures
To the fullest extent permitted by Maine law, signatures in electronic form (including via secure electronic medical-record platforms) are deemed original and enforceable.
9.6 Counterparts
This Directive may be executed in multiple counterparts, each of which is deemed an original, and all of which constitute one instrument.
10. EXECUTION BLOCK
[// GUIDANCE: Maine EMS currently requires at least one witness (age 18+ and not the Clinician) OR notarization. Retain both blocks so the preparer can choose the appropriate method.]
10.1 Patient / Agent Signature
| Role | Name | Signature | Date |
|---|---|---|---|
| Patient | [PATIENT NAME] | _________ | ____ |
| Health-Care Agent (if applicable) | [AGENT NAME] | _________ | ____ |
10.2 Clinician Certification
I, the undersigned Clinician, attest that: (i) the Patient or duly authorized Agent has executed this Directive voluntarily and with decision-making capacity or lawful authority; (ii) I have consulted with the Patient/Agent regarding the medical implications; and (iii) I hereby issue and affirm this DNR medical order.
| Title | Name | Signature | Date | License # |
|---|---|---|---|---|
| Physician / APRN / PA | [CLINICIAN NAME] | _________ | ____ | [LICENSE #] |
10.3 Witness Acknowledgment
I declare that I am at least 18 years of age, not related to the Patient by blood, marriage, or adoption, not entitled to any portion of the Patient’s estate, and not directly involved in the Patient’s medical care. I witnessed the Patient/Agent execute this Directive voluntarily.
| Name | Signature | Date | Address |
|---|---|---|---|
| [WITNESS #1 NAME] | _________ | ____ | [ADDRESS] |
(Optional second witness)
10.4 Notarization (Optional Alternative to Witness)
State of Maine
County of [COUNTY]
On this _ day of _, 20___, before me, the undersigned notary public, personally appeared [PATIENT NAME] (and [AGENT NAME], if any), proved to me through satisfactory evidence of identification, to be the person(s) whose name(s) is/are signed on this instrument, and acknowledged to me that (he/she/they) executed it voluntarily for its stated purpose.
Notary Public, State of Maine
My Commission Expires: ____
11. ATTACHMENTS / EXHIBITS
A. Photocopy of Patient’s Government-Issued Identification
B. Photocopy of Agent’s Health-Care Power of Attorney (if any)
C. Maine EMS-approved DNR Bracelet/Necklace Order Form (if applicable)
[// GUIDANCE: Attach additional exhibits as needed, e.g., facility-specific DNR policy acknowledgments, translation certificates, or electronic registry confirmations.]
END OF DOCUMENT
[// GUIDANCE: After customization, ensure that (i) the executed Directive is provided to all treating providers and uploaded to the Patient’s electronic medical record, and (ii) the original is readily accessible in an emergency (e.g., on distinctive paper at bedside or stored with personal identification). Maine EMS personnel are trained to look for the official gold-colored DNR form or approved bracelet—comply with current color/format directives to avoid confusion.]