NORTH CAROLINA

DO NOT RESUSCITATE (DNR) MEDICAL DIRECTIVE

(EMS-Recognized Form – Print on yellow (“canary”) card stock for field validity)

[// GUIDANCE: This template is drafted to comport with current North Carolina statutory and regulatory requirements for EMS-recognized DNR orders, while also providing the substantive protections, definitions, and boilerplate a practitioner may wish to see in a robust medical directive. Delete bracketed guidance before finalizing.*

[// GUIDANCE: All customizable data fields appear in ALL-CAPS WITH UNDERSCORES and should be completed or deleted prior to execution.]

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
9. General Provisions
10. Execution Block

1. DOCUMENT HEADER

1.1 Title & Parties.
This Do Not Resuscitate Medical Directive (this “Directive”) is made by [PATIENT FULL LEGAL NAME] (“Patient”), residing at [PATIENT ADDRESS], in consultation with [ATTENDING PHYSICIAN/PA/NP NAME & LICENSE NO.] (“Provider”) and, if applicable, the Patient’s lawfully-appointed health care agent, [HEALTH CARE AGENT NAME] (“Agent”).

1.2 Effective Date.
This Directive becomes effective on [EFFECTIVE DATE] (“Effective Date”).

1.3 Governing Law.
This Directive shall be interpreted exclusively under the health-care laws of the State of North Carolina.

1.4 Purpose & Consideration.
Patient issues this Directive freely and voluntarily to give legally enforceable instructions that no cardiopulmonary resuscitation (CPR) or other life-prolonging resuscitative measures be attempted in the event of cardiac or respiratory arrest. Provider acknowledges receipt of these instructions and, in consideration of the mutual promises herein, agrees to incorporate this Directive into the Patient’s medical record and to communicate the same to Emergency Medical Services (“EMS”) personnel and other health-care providers.

2. DEFINITIONS

For purposes of this Directive, the following terms have the meanings set forth below; capitalized terms not defined herein have the meanings ascribed to them in North Carolina health-care statutes and regulations:

“Agent” – The natural person appointed under a valid North Carolina Health Care Power of Attorney to make medical decisions for Patient when Patient lacks capacity.

“Cardiopulmonary Resuscitation” or “CPR” – Any medical intervention to restore cardiac or respiratory function, including chest compressions, defibrillation, or ventilation.

“DNR Identifier” – A paper, bracelet, necklace, or other tangible item meeting NC Office of EMS specifications evidencing the existence of a DNR order.

“EMS” – Emergency Medical Services personnel licensed or credentialed under North Carolina law.

“Good Faith” – Honest intent to act without deliberate wrongdoing, malice, or gross negligence, consistent with professional standards.

“MOST Form” – A Medical Order for Scope of Treatment as defined by North Carolina regulations, which may incorporate DNR instructions.

“Provider” – The physician, physician assistant, or nurse practitioner who issues and signs this Directive.

“Resuscitative Measures” – Interventions intended to restart or support heart or lung function, including but not limited to CPR, advanced airway management, and administration of resuscitative medications.

3. OPERATIVE PROVISIONS

3.1 Order Not to Resuscitate.
Provider shall issue—and by countersigning below does hereby issue—a medical order directing that no CPR or other Resuscitative Measures be attempted on Patient in the event of cardiac or respiratory arrest.

3.2 Scope of Treatment.
Except as limited by Section 3.1, Patient does / does not [SELECT ONE] consent to other medically indicated interventions (e.g., comfort care, antibiotics, artificial nutrition/hydration).
[// GUIDANCE: If broader MOST-type orders are desired, incorporate the full MOST check-box matrix here.]

3.3 EMS Recognition Requirements.
a. This Directive shall be printed on yellow card stock and kept readily available.
b. A conforming DNR Identifier may be worn by Patient.
c. EMS personnel acting in good faith may rely on this Directive or on a DNR Identifier until presented with written revocation.

3.4 Witness Requirements.
This Directive must be signed in the presence of two (2) adult witnesses, each of whom:
i. is at least 18 years old;
ii. is not related to Patient by blood, marriage, or adoption;
iii. will not inherit from or financially benefit by Patient’s death; and
iv. is not directly involved in Patient’s health-care provision.

[// GUIDANCE: A notarial acknowledgment may be added for belt-and-suspenders validity but is not expressly required for EMS recognition in NC.]

3.5 Revocation.
Patient (or Agent, if Patient lacks capacity) may revoke this Directive at any time by:
a. notifying Provider or attending EMS personnel orally or in writing;
b. destroying this document and any DNR Identifier; or
c. executing a superseding medical order.

3.6 Duration.
This Directive remains in effect until revoked pursuant to Section 3.5 or replaced by a duly executed and later-dated directive.

4. REPRESENTATIONS & WARRANTIES

4.1 Patient Representations.
a. Patient is of sound mind and at least 18 years of age.
b. Patient understands the medical consequences of refusing resuscitative measures.
c. Execution of this Directive is voluntary and not the product of duress or undue influence.

4.2 Provider Representations.
Provider has:
a. discussed with Patient (or Agent) the nature, risks, and alternatives to resuscitative measures;
b. confirmed Patient’s capacity at the time of signing; and
c. entered this Directive in Patient’s permanent medical record.

4.3 Survival.
The representations and warranties in this Article 4 survive execution and remain effective for the term of this Directive.

5. COVENANTS & RESTRICTIONS

5.1 Provider Covenants.
Provider shall take reasonable steps to:
a. inform all treating personnel of the existence of this Directive;
b. ensure that the Directive accompanies Patient upon inter-facility transfer; and
c. honor the Directive unless and until revoked.

5.2 Patient Covenants.
Patient (or Agent) shall:
a. maintain the yellow original in an easily accessible location;
b. notify Provider promptly of any revocation; and
c. provide copies to health-care facilities as needed.

6. DEFAULT & REMEDIES

6.1 Events of Default.
a. Provider’s failure to honor this Directive in the absence of revocation.
b. EMS or other personnel’s disregard of a valid DNR Identifier when presented.

6.2 Cure Period.
Upon learning of a potential default, the defaulting party shall promptly take corrective action to align treatment with this Directive, to the extent medically feasible.

6.3 Remedies.
Subject to Section 7 (Risk Allocation), the non-defaulting party may seek equitable relief, including specific performance or injunctive relief, in a court of competent jurisdiction to enforce this Directive.

[// GUIDANCE: Monetary damages are rarely applicable in end-of-life contexts; equitable remedies are the principal enforcement mechanism.]

7. RISK ALLOCATION

7.1 Indemnification (Provider Protection).
Patient (and Patient’s estate) shall indemnify and hold harmless Provider, EMS personnel, and any health-care facility or professional (each, an “Indemnified Party”) from and against any and all claims, liabilities, or expenses arising out of good-faith compliance with this Directive, except to the extent an Indemnified Party’s conduct constitutes gross negligence or willful misconduct.

7.2 Limitation of Liability (Good-Faith Standard).
No Indemnified Party acting in good faith and in substantial compliance with this Directive shall be liable for civil damages or subject to professional discipline for withholding or withdrawing resuscitative measures.

7.3 Insurance.
Nothing herein shall be construed to diminish coverage under any professional or general liability insurance policy held by an Indemnified Party.

7.4 Force Majeure.
An Indemnified Party is excused from performance under this Directive to the extent compliance is impossible due to circumstances beyond reasonable control (e.g., mass casualty event, equipment failure, or legal prohibition).

8. DISPUTE RESOLUTION

8.1 Governing Law.
All disputes shall be determined under the laws of the State of North Carolina, without regard to its conflict-of-laws principles.

8.2 Forum.
Exclusive venue lies in the state courts of [COUNTY] County, North Carolina.

8.3 Alternative Dispute Mechanism.
Prior to litigation, parties shall seek non-binding review by the treating facility’s ethics committee (if available).

8.4 Injunctive Relief.
Nothing in this Article limits the right of any party to seek immediate injunctive relief to enforce or prevent material breach of this Directive.

9. GENERAL PROVISIONS

9.1 Amendment & Waiver.
This Directive may be amended only by a written instrument executed with the same formalities as this Directive. No waiver of any provision is effective unless in writing and signed by the waiving party.

9.2 Assignment.
Rights and obligations hereunder are personal to the parties and may not be assigned.

9.3 Successors & Assigns.
This Directive is binding upon and inures to the benefit of Patient’s heirs, executors, administrators, and legal representatives, and upon Provider’s permitted successors.

9.4 Severability.
If any provision of this Directive is held invalid or unenforceable, the remaining provisions remain in full force and effect and shall be construed to fulfill the Directive’s intent.

9.5 Entire Agreement.
This Directive constitutes the entire agreement concerning the subject matter and supersedes all prior oral or written statements.

9.6 Counterparts & Electronic Signatures.
This Directive may be executed in counterparts and by electronic signature in compliance with the North Carolina Uniform Electronic Transactions Act.

10. EXECUTION BLOCK

[// GUIDANCE: Use indelible ink. Signatures must be original (wet) for EMS recognition. Have each witness sign immediately after observing Patient’s signature.]

If Patient lacks capacity:

Provider Certification (required):

OPTIONAL NOTARIAL ACKNOWLEDGMENT
State of North Carolina )
County of [__] )

On this _ day of _, 20__, before me, a Notary Public for said State and County, personally appeared [NAME(S) OF SIGNATORY(IES)], known to me or satisfactorily proven to be the person(s) whose name(s) are subscribed to this instrument, and acknowledged that he/she/they executed the same for the purposes therein contained.

Notary Public: ____
My Commission Expires: __

[// GUIDANCE:
1. Provide copies to Patient, Agent, primary care physician, and any facility regularly treating Patient.
2. Place original on bright yellow card stock per NC OEMS protocol and affix to Patient’s chart or bedside.
3. Consider issuing an embossed or laminated DNR bracelet/necklace referencing the Effective Date.
4. Review annually or upon material change in Patient’s condition or wishes.]